The child survival impact of the Ghana Essential Health Interventions Program: A health systems strengthening plausibility trial in Northern Ghana

Abstract

Background The Ghana Health Service in collaboration with partner institutions implemented a five-year primary health systems strengthening program known as the Ghana Essential Health Intervention Program (GEHIP). GEHIP was a plausibility trial implemented in an impoverished region of northern Ghana around the World Health Organizations (WHO) six pillars combined with community engagement, leadership development and grassroots political support, the program organized a program of training and action focused on strategies for saving newborn lives and community-engaged emergency referral services. This paper analyzes the effect of the GEHIP program on child survival. Methods Birth history data assembled from baseline and endline surveys are used to assess the hazard of child mortality in GEHIP treatment and comparison areas prior to and after the start of treatment. Difference-in-differences (DiD) methods are used to compare mortality change over time among children exposed to GEHIP relative to children in the comparison area over the same time period. Models test the hypothesis that a package of systems strengthening activities improved childhood survival. Models adjusted for the potentially confounding effects of baseline differentials, secular mortality trends, household characteristics such as relative wealth and parental educational attainment, and geographic accessibility of clinical care. Results The GEHIP combination of health systems strengthening activities reduced neonatal mortality by approximately one half (HR = 0.52, 95% CI = 0.28,0.98, p = 0.045). There was a null incremental effect of GEHIP on mortality of post-neonate infants (from 1 to 12 months old) (HR = 0.72; 95% CI = 0.30,1.79; p = 0.480) and post-infants (from 1 year to 5 years old) -(HR = 1.02; 95% CI = 0.55–1.90; p = 0.940). Age-specific analyses show that impact was concentrated among neonates. However, effect ratios for post-infancy were inefficiently assessed owing to extensive survival history censoring for the later months of childhood. Children were observed only rarely for periods over 40 months of age. Conclusion GEHIP results show that a comprehensive approach to newborn care is feasible, if care is augmented by community-based nurses. It supports the assertion that if appropriate mechanisms are put in place to enable the various pillars of the health system as espoused by WHO in rural impoverished settings where childhood mortality is high, it could lead to accelerated reductions in mortality thereby increasing survival of children. Policy implications of the pronounced neonatal effect of GEHIP merit national review for possible scale-up.

The fertility impact of achieving universal health coverage in an impoverished rural region of Northern Ghana

“…Comparison area CHPS coverage also improved, but at a much lower rate that achieved an end of project population coverage rate of half that of the treatment area. As a mechanism for improving health care equity, access, and effectiveness, GEHIP was shown to have had an impact on neonatal mortality 29 . And assessment of referral volume can maternal mortality ratios showed that emergency referral and facility based care strategies of the program saved maternal lives 30 .…”

“…Conducted in the Upper East Region over the 2010 to 2016 period, the GEHIP initiative greatly improved the provision of community-based primary health care through CHPS. The mortality impact of GEHIP on neonates was pronounced among neonates 29 . Mortality also declined significantly among children aged 1 to 59 months, but this trend was realized in both treatment and comparison areas owing to the successful improvement in IMCI care in all UER districts 31 .…”

“…Birth histories were compiled using interviewing instruments published by the Ghana Demographic and Health Survey of 2008 33 for interviews of all women resident in GEHIP sample households aged 15 to 49. Sample size and power calculations were designed to permit difference-in-difference evaluation of posited child survival effects of GEHIP exposure 31 . In the baseline survey (available as Extended data) 34 , 66 clusters in GEHIP intervention and comparison districts were randomly selected based on the enumeration areas of the 2010 census (Ghana Statistical Service 2004).…”

“…If GEHIP results were extended to the national program, Ghana could achieve UHC within five years if its strategies were to be replicated 27,28 . Moreover, CHPS coverage effects of GEHIP exposure was associated with improved childhood survival 29 . Its emergency referral strategies were associated with reduced maternal mortality 30 .…”

Community perceptions of universal health coverage in eight districts of the Northern and Volta regions of Ghana

“…Recommendations emerging from this investigation focusing on leadership development strategies were assembled into interventions of a four district five-year experiment known as the Ghana Essential Health Interventions Programme (GEHIP) [33]. GEHIP tested means of improving the management of CHPS start-up activities and demonstrated ways to accelerate coverage, improve emergency referral services, and reduce mortality [34].…”