USAID Systems for Health Project FINAL REPORT...RING Resiliency in Northern Ghana (a USAID project) RMNCAH Reproductive, Maternal, Newborn, Child, and Adolescent Health RRIRV Request

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 Results ..................................................................... 26

The Way Forward: Continuation and

Eventual Scale-up ............................................................31

Technical Achievements .................................................... 32

Maternal, Newborn, and Child Health ................................ 32


Evidence-based Interventions ........................................ 35

Key Results ..................................................................... 37

Nutrition ............................................................................42


Key Results .....................................................................44

Family Planning and Reproductive Health ..........................46


Key Results .....................................................................48

Malaria ............................................................................... 53

Key Activities and Outputs .............................................54

Key Results ..................................................................... 55

Infection Prevention and Control ......................................60


Key Results .....................................................................62

Keys to Success .............................................................. 63

Community-based Health Planning and Services Infrastructure ......................................................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

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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.


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


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


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


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


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


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


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


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


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


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


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


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


Disag-gregation

Frequency of


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


Disag-gregation

Frequency of


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


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


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


Disag-gregation

Frequency of


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


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


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


Disag-gregation

Frequency of


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)


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


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)


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


Disag-gregation

Frequency of


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.


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


Disag-gregation

Frequency of


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


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.


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


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


Disag-gregation

Frequency of


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


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


Disag-gregation

Frequency of


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


Central 91.1% 89.7%

G.Accra 91.4% 93.0%

Northern 73.0% 87.2%

Volta 77.3% 83.5%


87.9% (GMHS 2017)

continued

93


Disag-gregation

Frequency of


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


and Endline

All N/A

N/A N/ADHS 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%


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



Central 57.6% N/A

G.Accra 71.3% N/A

Northern 52.8% N/A

Volta 38.9% N/A


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)


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)


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


Disag-gregation

Frequency of


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


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


Baseline and

Endline

All



Central 60.9%

G.Accra 52.8%

Northern 64.7%

Volta 44.1%


USE 16 Number of babies who received postnatal care within two days of childbirth in USG-supported programs


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


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



Central 51.1%

G.Accra 76.4%

Northern 41.0%

Volta 62.7%


continued

95


Disag-gregation

Frequency of


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


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


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


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)


and Endline

All



Central 69.7% N/A 84.3%

G.Accra 52.8% N/A 61.7%


Volta 76.3% N/A 77.8%


N/A 69.1% (GMIS 2016)

USE 23

% of children <5 who slept under an ITN the previous night


and Endline

All



Central 51.2% N/A 61.9%

G.Accra 25.9% N/A 32.6%


Volta 66.3% N/A 54.8%


N/A 45.5% (GMIS 2016)

USE 24 % of pregnant women who slept under an ITN the previous night


and Endline

All



Central 44.7% 58.2%

G.Accra 17.8% 36.6%

Northern 49.6% 58.8%

Volta 68.6% 56.3%


— (GMIS 2016)

USE 25

% of children <5 who receive ACT treatment within 24 hours of the onset of fever

Region Baseline and

Endline

All



Central 32.7%

G.Accra 19.8%

Northern 9.7%

Volta 29.1%


continued

96


Disag-gregation

Frequency of


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


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


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)


Endline

All



Central 21.9% N/A

G.Accra 22.7% N/A

Northern 14.1% N/A

Volta 10.5% N/A


N/A

USE 29

% of children 0-5 months who are exclusively breastfed


Endline

All



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



Central 46.7%

G.Accra 42.4%

Northern 47.5 %

Volta 48.7%


continued

97


Disag-gregation

Frequency of


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)


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


endline

All



Central 70.2%

G.Accra 59.6%

Northern 82.1%

Volta 69.9%


OUT 5 Prevalence of children under five years of age below minus two standard deviations from median height for age of reference population (stunting)


endline

All



Central 18.4%

G.Accra 5.6%

Northern 26.5%

Volta 14.2%


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


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


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



104


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


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.

108


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


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

Documents

USAID Systems for Health Project FINAL REPORT...RING Resiliency in Northern Ghana (a USAID project) RMNCAH Reproductive, Maternal, Newborn, Child, and Adolescent Health RRIRV Request