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Ghana has committed politically, legislatively, and fiscally to providing universal health insurance coverage for its population with the intent of reducing financial barriers to utilization of health care.. However, under current cost and enrollment projections the system will not be financially sustainable in the long term, so there is more work to do. This book provides an important evidence-based review of the current performance of Ghana's health system and options for reform. As such, it provides an overall picture of the Ghana health sector, how things were and how things have changed, as well as a situational analysis of the performance of the health delivery and health financing systems using the latest available data. Finally, it discusses key reform issues and options in the context of the country's likely fiscal space. An important and valuable contribution of this book is its examination of how Ghana is performing compared to its neighboring countries and compared to other countries with similar incomes and health spending, providing global benchmarks for Ghana's health system performance.

Background Though the World Health Organization (WHO) recommended Infant and Young Child Feeding (IYCF) indicators have been in use, little is known about their association with child nutritional status. The objective of this study was to explore the relationship between IYCF indicators (timing of complementary feeding, minimum dietary diversity, minimum meal frequency and minimum acceptable diet) and child growth indicators. Methods A community-based cross-sectional survey was carried out in November 2013. The study population comprised mothers/primary caregivers and their children selected using a two-stage cluster sampling procedure. Results Of the 1984 children aged 6–23 months; 58.2 % met the minimum meal frequency, 34.8 % received minimum dietary diversity (≥4 food groups), 27.8 % had received minimum acceptable diet and only 15.7 % received appropriate complementary feeding. With respect to nutritional status, 20.5 %, 11.5 % and 21.1 % of the study population were stunted, wasted and underweight respectively. Multiple logistic regression analysis revealed that compared to children who were introduced to complementary feeding either late or early, children who started complementary feeding at six months of age were 25 % protected from chronic malnutrition (AOR = 0.75, CI = 0.50 - 0.95, P  = 0.02). It was found that children whose mothers attended antenatal care (ANC) at least 4 times were 34 % protected [AOR 0.66; 95 % CI (0.50 - 0.88)] against stunted growth compared to children born to mothers who attended ANC less than 4 times. Children from households with high household wealth index were 51 % protected [AOR 0.49; 95 % CI (0.26 - 0.94)] against chronic malnutrition compared to children from households with low household wealth index. After adjusting for potential confounders, there was a significant positive association between appropriate complementary feeding index and mean WLZ (β = 0.10, p  = 0.005) but was not associated with mean LAZ. Conclusions The WHO IYCF indicators better explain weight-for-length Z-scores than length-for-age Z-scores of young children in rural Northern Ghana. Furthermore, a composite indicator comprising timely introduction of solid, semi-solid or soft foods at 6 months, minimum meal frequency, and minimum dietary diversity better explains weight-for-length Z-scores than each of the single indicators.

Variations exist in the surgical techniques used for caesarean section and many have not been rigorously assessed in randomised controlled trials. We aimed to assess whether any surgical techniques were associated with improved outcomes for women and babies. CORONIS was a pragmatic international 2×2×2×2×2 non-regular fractional, factorial, unmasked, randomised controlled trial that examined five elements of the caesarean section technique in intervention pairs. CORONIS was undertaken at 19 sites in Argentina, Chile, Ghana, India, Kenya, Pakistan, and Sudan. Each site was assigned to three of the five intervention pairs: blunt versus sharp abdominal entry; exteriorisation of the uterus for repair versus intra-abdominal repair; single-layer versus double-layer closure of the uterus; closure versus non-closure of the peritoneum (pelvic and parietal); and chromic catgut versus polyglactin-910 for uterine repair. Pregnant women were eligible if they were to undergo their first or second caesarean section through a planned transverse abdominal incision. Women were randomly assigned by a secure web-based number allocation system to one intervention from each of the three assigned pairs. All investigators, surgeons, and participants were unmasked to treatment allocation. The primary outcome was the composite of death, maternal infectious morbidity, further operative procedures, or blood transfusion (>1 unit) up to the 6-week follow-up visit. Women were analysed in the groups into which they were allocated. The CORONIS Trial is registered with Current Controlled Trials: ISRCTN31089967. Between May 20, 2007, and Dec 31, 2010, 15 935 women were recruited. There were no statistically significant differences within any of the intervention pairs for the primary outcome: blunt versus sharp entry risk ratio 1·03 (95% CI 0·91–1·17), exterior versus intra-abdominal repair 0·96 (0·84–1·08), single-layer versus double-layer closure 0·96 (0·85–1·08), closure versus non-closure 1·06 (0·94–1·20), and chromic catgut versus polyglactin-910 0·90 (0·78–1·04). 144 serious adverse events were reported, of which 26 were possibly related to the intervention. Most of the reported serious adverse events were known complications of surgery or complications of the reasons for the caesarean section. These findings suggest that any of these surgical techniques is acceptable. However, longer-term follow-up is needed to assess whether the absence of evidence of short-term effects will translate into an absence of long-term effects. UK Medical Research Council and WHO.

Covid-19 has had devastating effect on health systems and health utilization globally. Maternal and newborn care were adversely affected but little or nothing is known about the impact it has caused to it. This study seeks to determine the effect of Covid-19 on healthcare utilization with specifics on Antenatal, Postnatal, Deliveries and Out-patient attendance. The study uses secondary data obtained from the four (4) Claims Processing Centres of the National Health Insurance Authority. Through the use of convenient sampling, a total of 502 facilities were selected for inclusion in the research. The study used a longitudinal claims submitted from a cross-section of health facilities namely Community-Based Health Planning and Services, Maternity Homes, Health Centers, Clinics, Primary, Secondary, and Tertiary Hospitals for Antenatal, Postnatal, Out-patient consultations and Delivery attendances from January 2018 to December 2021. Data before and during the Covid-19 pandemic were compared. Segmented regression analysis as an interrupted time series analysis was employed to assess the effect of the pandemic on utilization of services. The results indicate that Covid-19 had a significant impact on healthcare utilization in Ghana. Month-on-month, antenatal and out-patient utilization decreased by 21,948.21 and 151,342.40, respectively. Postnatal and delivery services saw an insignificant monthly increase of 37.76 and 1,795.83 from the onset of the covid-19 pandemic and the introduction of movement restrictions. This decline was observed across all care levels, except for Community-Based Health Planning and Services, which showed a slight increase. Also, the results indicate projected average misses of scheduled antenatal, postnatal, out-patient reviews, and deliveries at 21,037.75, 6,428.23, 141,395.30 and 4,745.63 patients respectively. The study reveals that Covid-19 led to a decrease in utilization of healthcare which affected pregnant women and newborn care as well. It was evident from the results that community-based healthcare is more resilient and efficient in delivering healthcare amidst the pandemic. In our quest to achieve Universal Health Coverage by 2030, Ghana's health system should improve on the community-based healthcare system and include technology in its healthcare delivery for the people.

Background Frailty is a major public health concern among older people, particularly in resource-limited settings where it significantly reduces Quality of Life (QoL) and increases vulnerability to poor health outcomes. While social and environmental factors influencing frailty have been studied in high-income countries, evidence from Sub-Saharan Africa remains scarce. This study examined the relationship between frailty and QoL in Ghana, focusing on the mediating roles of social networks and perceptions of safety across rural and urban settings. Methods We analysed nationally representative data from the World Health Organisation’s Study on Global Ageing and Adult Health (SAGE) in Ghana. The data included older people ( N  = 2077), aged 60 years and above. Frailty was measured using a 30-item Frailty Index, and QoL was assessed using a composite score from the WHOQOL-BREF. We conducted bootstrapped parallel mediation analysis to examine the indirect effects of social networks and perception of safety on the frailty–QoL relationship, with subgroup analyses comparing urban and rural settings. Results The overall frailty prevalence was 39.7%, with slightly higher rates in rural (43.1%) than urban areas (35.8%). Frailty was significantly associated with lower QoL across both rural and urban settings. The total effect of frailty on QoL was strong and significant in both rural (effect = − 5.44, 95% CI: − 6.00, − 4.88) and urban areas (effect = − 5.97, 95% CI: − 6.65, − 5.29). In rural areas, perception of safety was found to be a significant mediator in the association between frailty and QoL (indirect effect = 0.08, 95% CI: 0.02, 0.15), while in urban areas, social networks were the key mediator (indirect effect = − 0.22, 95% CI: − 0.45, − 0.02). The combined total indirect effect was not significant in both urban (–0.24, 95% CI: − 0.48, 0.00) and rural (–0.05, 95% CI: − 0.24, 0.15) areas. Conclusion Context specific interventions are required to improve the well-being of older people in rural and urban regions of Ghana. Strengthening community safety and cohesion in rural areas and enhancing social connectedness in urban settings may help reduce the impact of frailty, as well as improve QoL among older people in Ghana. Trial registration Not applicable.

Vaccination has emerged as the most cost-effective public health strategy for maintaining population health, with various social and economic benefits. These vaccines, however, cannot be effective without widespread acceptance. The present study examines the effect of media attention on COVID-19 vaccine hesitancy by incorporating fear of COVID-19 as a mediator, whereas trust in leadership served as a moderator. An analytical cross-sectional study is performed among rural folks in the Wassa Amenfi Central of Ghana. Using a questionnaire survey, we were able to collect 3079 valid responses. The Smart PLS was used to estimate the relationship among the variables. The results revealed that media attention had a significant influence on vaccine hesitancy. Furthermore, the results showed that fear of COVID-19 played a significant mediating role in the relationship between media and vaccine hesitancy. However, trust in leadership had an insignificant moderating relationship on the fear of COVID-19 and vaccine hesitancy. The study suggests that the health management team can reduce vaccine hesitancy if they focus on lessening the negative impact of media and other antecedents like fear on trust in leadership.

The COVID-19 pandemic affected expectant mothers seeking maternal health services in most developing countries. Access and utilization of maternal health services including antenatal care (ANC) attendance and skilled delivery declined drastically resulting in adverse pregnancy outcomes. This study assessed pregnancy outcomes before and during COVID-19 pandemic in Tamale Metropolis, Ghana. A retrospective cohort study design was employed. A random sampling technique was used to select 450 women who delivered before or during the COVID-19 pandemic in Tamale Metropolis, Ghana. The respondents were interviewed using structured questionnaire at their homes. In this study, the data collected were socio-demographics characteristics, ANC attendance, before or during pandemic delivery, place of delivery and birth outcomes. Chi-square test and bivariate logistic regression analyses were performed under significant level of 0.05 to determine factors associated with the outcome variables. Of the 450 respondents, 51.8% were between 26 and 30 years of age. More than half (52.2%) of the respondents had no formal education and 93.3% were married. The majority (60.4%) of the respondents described their residence as urban setting. About 31.6% of the women delivered before the pandemic. The COVID-19 pandemic influenced place of delivery. The proportion of women who attended at least one ANC visit (84.5% before vs 70.5% during), and delivered at a hospital (76.8% before vs 72.4% during) were higher before the pandemic. More women were likely to deliver at home during COVID-19 (OR: 2.38, 95%CI: 1.52-3.74, p<0.001). Similarly, there was statistically significance difference between before and during COVID-19 delivery on at least one ANC attendance (OR: 2.72, 95%CI: 1.58-1.67, p<0.001). Women who delivered during COVID-19 were about twice more likely to develop complications (OR: 1.72, 95%CI: 1.03-2.87, p = 0.04). ANC attendance and health facility delivery decreased while pregnancy complications increased during COVID-19. During disease outbreaks, outreach engagement strategies should be devised to increase access and utilization of maternal health services for marginalized and underserved populations. The capacity of health workers should be strengthened through skills training to manage adverse birth outcomes.

Background Although Ghana has made modest progress in the fight against HIV, the prevalence among women remains high, with 66% of people living with HIV in the country being females. Besides, approximately 71% of people with HIV in Ghana know their status compared with the global average of 85% and the WHO target of 95%. This relatively low percentage of people with HIV, knowing their status, tends to derail Ghana’s attainment of SDG 3.3. Against this backdrop, this paper examines the drivers of HIV testing status among women of reproductive age in Ghana to inform policy. Methods We analysed a nationally representative sample of 14,997 women aged 15–49 from the 2022 Ghana Demographic and Health Survey (GDHS). A pooled and disaggregated (rural vs. urban) multiple logistic regressions were estimated to examine the drivers of HIV testing uptake among women in Ghana. Results Approximately 54% of the sampled women had ever tested for HIV. Women residing in urban areas had a high HIV testing status (58.83%) relative to their counterparts in rural areas (48.91%). At the bivariate level, ever-married (66%) and pregnant women (69%) had a higher HIV testing uptake relative to their never-married (39%) and not-pregnant (52%) counterparts. Findings from the multivariate logistic regressions highlight significant similarities in the drivers of HIV testing among rural and urban women, albeit some of the predictors are exclusive to either rural or urban areas. HIV testing is significantly predicted by wealth status, education, age, marital status, employment, pregnancy status, and administrative region of residence. Though women in the richer and richest wealth categories were more likely to undertake HIV testing in both urban and rural areas, the positive effect was more pronounced among women residing in urban areas. Besides, the level of education predicted the HIV testing status of women in both rural and urban areas, albeit the effect was more pronounced in the rural areas. Moreover, pregnant women in the urban areas were more likely to test for HIV relative to their counterparts in the rural areas. Conclusion The study demonstrated the need to target women of lower socio-economic status and those pregnant, especially in rural areas, for HIV public health education interventions. Such interventions are crucial in increasing HIV testing to avert severe HIV/AIDS morbidity through appropriate ART and thus avoid preventable deaths. The study also highlights the need to improve the availability of testing kits in rural areas to address the supply-side challenges facing public health facilities in rural areas.

National levels of personal health-care access and quality can be approximated by measuring mortality rates from causes that should not be fatal in the presence of effective medical care (ie, amenable mortality). Previous analyses of mortality amenable to health care only focused on high-income countries and faced several methodological challenges. In the present analysis, we use the highly standardised cause of death and risk factor estimates generated through the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to improve and expand the quantification of personal health-care access and quality for 195 countries and territories from 1990 to 2015. We mapped the most widely used list of causes amenable to personal health care developed by Nolte and McKee to 32 GBD causes. We accounted for variations in cause of death certification and misclassifications through the extensive data standardisation processes and redistribution algorithms developed for GBD. To isolate the effects of personal health-care access and quality, we risk-standardised cause-specific mortality rates for each geography-year by removing the joint effects of local environmental and behavioural risks, and adding back the global levels of risk exposure as estimated for GBD 2015. We employed principal component analysis to create a single, interpretable summary measure–the Healthcare Quality and Access (HAQ) Index–on a scale of 0 to 100. The HAQ Index showed strong convergence validity as compared with other health-system indicators, including health expenditure per capita (r=0·88), an index of 11 universal health coverage interventions (r=0·83), and human resources for health per 1000 (r=0·77). We used free disposal hull analysis with bootstrapping to produce a frontier based on the relationship between the HAQ Index and the Socio-demographic Index (SDI), a measure of overall development consisting of income per capita, average years of education, and total fertility rates. This frontier allowed us to better quantify the maximum levels of personal health-care access and quality achieved across the development spectrum, and pinpoint geographies where gaps between observed and potential levels have narrowed or widened over time. Between 1990 and 2015, nearly all countries and territories saw their HAQ Index values improve; nonetheless, the difference between the highest and lowest observed HAQ Index was larger in 2015 than in 1990, ranging from 28·6 to 94·6. Of 195 geographies, 167 had statistically significant increases in HAQ Index levels since 1990, with South Korea, Turkey, Peru, China, and the Maldives recording among the largest gains by 2015. Performance on the HAQ Index and individual causes showed distinct patterns by region and level of development, yet substantial heterogeneities emerged for several causes, including cancers in highest-SDI countries; chronic kidney disease, diabetes, diarrhoeal diseases, and lower respiratory infections among middle-SDI countries; and measles and tetanus among lowest-SDI countries. While the global HAQ Index average rose from 40·7 (95% uncertainty interval, 39·0–42·8) in 1990 to 53·7 (52·2–55·4) in 2015, far less progress occurred in narrowing the gap between observed HAQ Index values and maximum levels achieved; at the global level, the difference between the observed and frontier HAQ Index only decreased from 21·2 in 1990 to 20·1 in 2015. If every country and territory had achieved the highest observed HAQ Index by their corresponding level of SDI, the global average would have been 73·8 in 2015. Several countries, particularly in eastern and western sub-Saharan Africa, reached HAQ Index values similar to or beyond their development levels, whereas others, namely in southern sub-Saharan Africa, the Middle East, and south Asia, lagged behind what geographies of similar development attained between 1990 and 2015. This novel extension of the GBD Study shows the untapped potential for personal health-care access and quality improvement across the development spectrum. Amid substantive advances in personal health care at the national level, heterogeneous patterns for individual causes in given countries or territories suggest that few places have consistently achieved optimal health-care access and quality across health-system functions and therapeutic areas. This is especially evident in middle-SDI countries, many of which have recently undergone or are currently experiencing epidemiological transitions. The HAQ Index, if paired with other measures of health-system characteristics such as intervention coverage, could provide a robust avenue for tracking progress on universal health coverage and identifying local priorities for strengthening personal health-care quality and access throughout the world. Bill & Melinda Gates Foundation.

While the practice of polygyny is common in Ghana, little is known about its impact on the use of reproductive health services. The aim of this study was to assess the relationship between polygynous marriage and the utilisation of skilled antenatal care (ANC), assisted skilled birth, and modern contraceptive services among married women in Ghana. Secondary data from the 2017 Ghana Maternal Health Survey were used for this study. The study included a weighted sample of 9,098 married women aged 15–49 years. We used multivariable logistic regression models to assess the association between polygyny and each outcome variables. Sensitivity analysis was conducted to assess the dose–response relationship between polygyny and each outcome variable. The prevalence of eight or more ANC contacts, assisted skilled births, and use of modern contraception were 47.0%, 81.4%, and 25.4%, respectively. The prevalence of women in polygynous marriages was 15.3%. Compared to monogynous marriage, polygynous marriage was associated with 19% lower odds of having eight plus ANC contacts (adjusted odds ratio [aOR] 0.81, 95% CI: 0.69, 0.96), 25% lower odds of having assisted skilled birth (aOR 0.75, 95% CI: 0.63, 0.89), and 19% lower odds of modern contraceptive utilisation (aOR 0.81, 95% CI: 0.66, 0.99). Interventions on reproductive health may need to prioritise women in polygynous marriages in order to improve the utilisation of skilled ANC, assisted skilled birth, and modern contraceptive services.