ACCELERATING CHILD SURVIVAL AND DEVELOPMENT (ACSD)

Final Report The Retrospective Evaluation of ACSD: Ghana

Submitted to UNICEF on 7 October 2008

Institute for International Programs Johns Hopkins Bloomberg School of Public Health Baltimore, MD

Disclaimer: This report was prepared by IIP-JHU under contract with UNICEF. All photos were taken by members of the IIP-JHU evaluation team after requesting permission from those who were photographed. All text, data, photos and graphs should be cited with permission from the authors and UNICEF.

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IIP-JHU | Retrospective evaluation of ACSD in Ghana

Summary Introduction UNICEF implemented the Accelerated Child Survival and Development (ACSD) project between 2001 and 2005 in 11 countries in Africa with support from Canadian CIDA. The aim of ACSD was to reduce mortality among children less than five years of age by working with governments and other partners to increase coverage with a set of proven interventions. In the “high-impact” countries of Benin, Ghana, Mali and Senegal, a total of 16 districts worked to deliver the full set of interventions grouped into three packages: “EPI+” including vaccinations, vitamin A supplementation and the use of insecticide-treated nets (ITNs) for the prevention of malaria; “IMCI+” including promotion of exclusive breastfeeding for six months, timely complementary feeding, use of iodized salt and improved and integrated management at the health facility and community levels of children suffering from pneumonia, malaria and diarrhea, including home-based ORS use, treatment of malaria, and treatment of pneumonia with antibiotics; and “ANC+” including intermittent preventive treatment of malaria with SP (Fansidar) for pregnant women (IPTp), tetanus immunization during pregnancy to prevent maternal and neonatal tetanus and supplementation with iron/folic acid during pregnancy and with vitamin A post-partum. An internal evaluation by UNICEF estimated through modeling that the levels of coverage achieved through ACSD were associated with about a 20 percent reduction in all-cause under-five mortality relative to comparison districts in participating districts in four “high-impact” countries. This retrospective evaluation was commissioned by UNICEF to confirm these findings and provide additional information that could be used th in planning effective programs to reduce child mortality and achieve the 4 Millennium Development Goal (MDG-4) in poor countries in Africa. The IIP evaluation team worked with ACSD managers at international and national levels to develop a generic ACSD framework that defined the pathways through which ACSD activities were expected to lead to reductions in child mortality and improvements in child nutritional status. The generic framework served as the “backbone” of the evaluation design. The country-specific evaluations also addressed equity across socioeconomic and ethnic groups, for urban-rural residence and for girl and boy children. At the request of UNICEF, the evaluation does not include an economic evaluation or a full assessment of the effects of ACSD on national policy.

Aim of the independent retrospective evaluation in Ghana The aim of the evaluation was to provide valid and timely evidence to child health planners and policy makers about the effectiveness of ACSD in reducing child mortality and improving child nutritional status in Ghana, as a part of the larger retrospective evaluation designed to inform future programs intended to reduce child mortality and accelerate progress toward MDG-4. Equity was also assessed. Two questions served as a guide to the analysis and reporting of the evaluation findings: a) Was ACSD implementation associated with improvements in coverage, nutrition and mortality over time? b) If so, was progress in the ACSD districts faster than that observed for the national comparison area?

ACSD implementation in Ghana UNICEF-Ghana received approximately $3.8 million from Canadian CIDA to support ACSD activities in i six “high-impact” districts (HIDs) with a combined population of about one million located in the Upper East region, and two expansion regions (Upper West and Northern regions) between 2001 and 2004. ACSD was implemented at the regional, district and sub-district levels in partnership with the Ghana

i

These six districts subdivided into eight districts in 2005 during redistricting.

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Health Service (GHS) and other development partners. The GHS supported EPI+ and ANC+ activities after 2004 by incorporating them into routine health services. After a hiatus of about one year, other ACSD activities received continued support from UNICEF funds, DANIDA and the Government of the Netherlands. ACSD inputs and activities in the Ghana HIDs, comprised of the entirety of the Upper East region, focused on: 1) Providing essential drugs, supplies, equipment and other support for outreach and campaign activities. ACSD-Ghana: a) provided an estimated 814 bicycles, 18 motorcycles and one vehicle to the HIDs over the course of the project for outreach and supervision activities; b) equipped health facilities with 553 refrigerator units for cold chain; c) supported local and national campaigns for vaccination and vitamin A supplementation, as well as routine health-facility outreach activities; and d) supplied commodities including vitamin A supplements, antihelminths, ORS, antimalarials and ITNs and retreatment chemicals for the prevention of malaria. 2) Supporting distribution and retreatment of ITNs at various levels. Over 200,000 ITNs were distributed in the HIDs between 2002 and 2005 through health centers, community outreach and distribution systems and campaigns. ACSD supported retreatment efforts at the community and facility levels, as well as through campaigns starting in 2004. All health workers and volunteers involved in ITN distribution and retreatment received training. 3) Training and supervising of facility-based workers. Forty-eight clinicians and three regional staff received standard 11-day IMCI training in 2005. 4) Training, equipping and supervising community health workers. ACSD-Ghana provided support for the training and supervision of over 1900 community-based agents (CBAs) in 600 communities to deliver messages to promote infant feeding, careseeking and treatment of childhood illness and ITNs, and immunization. The CBAs received health kits containing chloroquine, ORS, and handwashing and educational materials. ASCD also provided training and educational materials to community-based mothers’ groups for the promotion of infant feeding practices. 5) Supporting facility and outreach activities for pregnant women. The ANC+ package of ACSD included support for tetanus toxoid supplemental immunization activities, as well as facility and community distribution of postnatal vitamin A. IPTp was introduced in 2004 and ACSD supported its regional scale-up. Important barriers to full implementation of the ACSD implementation plan, as reported by program staff and reflected in project documentation, included: a) commodity insecurity, particularly stockouts of ITNs from late 2005 to late 2006; b) changes in the first-line antimalarial policy and the delayed authorization to distribute these drugs at the community level; and c) inadequate incentives and support and supervision systems for community-based workers.

Evaluation design and methods The IIP evaluation team worked with UNICEF-Ghana, the Government of Ghana and other partners to adapt the generic ACSD evaluation design to ACSD as implemented in Ghana. The intervention area was defined as the six HIDs located in the Upper East region. The comparison area was the remainder of Ghana excluding the urban areas of Greater Accra and Ashanti regions (Accra and Kumasi). The primary data sources for estimates of intervention coverage were DHS surveys conducted in 1998-99 and 2003 at baseline, and a national MICS survey carried out in 2006 supplemented by a special extension of the MICS in the HIDs carried out in 2007. Information was collected and summarized in order to document ACSD intervention activities and contextual factors through key informant interviews, document reviews and field visits carried out as part of a mapping exercise by investigators at Kwame Nkrumah University of Science and Technology (KNUST). All results and interpretations were reviewed with representatives of the Government of Ghana and UNICEF-Ghana.

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IIP-JHU | Retrospective evaluation of ACSD in Ghana

Results In Ghana, coverage for most of the ACSD interventions improved over time in the HIDs and reached the target coverage levels set by ACSD. Indicators showing positive trends over time in the HIDs included vaccinations, vitamin A, ITNs, antibiotics for suspected pneumonia, timely initiation of breastfeeding, exclusive breastfeeding, antenatal care, IPTp and the presence of a skilled attendant at delivery. Indicators that were observed to stagnate or decline included case management of common childhood illnesses, tetanus toxoid vaccination and postnatal vitamin A. Utilization of ITNs, antibiotics for pneumonia, breastfeeding initiation, skilled delivery and IPTp for pregnant women increased significantly more in the HIDs than in the comparison area. Appropriate management of childhood fever and diarrhea decreased in the HIDs, while stagnating in the comparison area; the difference in trends was statistically significant. For coverage, the answers to the two primary evaluation questions are as follows: (a) Coverage indicators related to vaccination, vitamin A, ITNs, feeding behaviors, antenatal care and skilled delivery improved over time in the HIDs and most reached the target coverage levels set by ACSD. Indicators of correct management of childhood illness declined over time. (b) Comparison with the rest of the country showed mixed results. Coverage increased rapidly for a greater number of interventions in the HIDs than in the comparison area. On the other hand, coverage declined significantly more for interventions related to the case management of childhood illness in the HIDs than in the comparison area. For nutritional status: (a) The HIDs showed a reduction between 1998-9 and 2007 in the prevalence of stunting and underweight, but not in wasting. The largest decline in stunting occurred between 1998-9 and 2003, before sufficient time had elapsed for interventions supported by ACSD to have had an impact on nutrition (b) Relative to the national comparison area, stunting declined faster in the HIDs in the period from 1998-9 to 2006-7. Most of this drop occurred before 2003, before ACSD inputs and activities could have contributed, but the decline was maintained and extended during the ACSD project period from 2003 onwards. Wasting declined significantly in the comparison area while remaining stable in the HIDs. For mortality: (a) There was a reduction of 20% in under-five mortality in the HIDs from before to after ACSD implementation, close to the ACSD goal of 25%. This trend was ascertained through the full birth history technique, and the reduction was close to reaching statistical significance (p=0.10). (b) Data on under-five mortality trends in the comparison area were available from a different source than those for the intervention area, with data points available through 2003. Other analyses suggest that mortality levels remained stable at around 115 deaths per thousand live births. Although these results must be interpreted with caution, they do suggest that the drop in underfive mortality was greater in the HIDs than in the national comparison area. The assessment of equity in coverage was limited to the period after ACSD implementation, because of limited sample sizes available from earlier periods. There were no inequalities in coverage based on the sex of the child, and few differences between urban and rural households. Results by socioeconomic level were mixed, with few inequalities for interventions delivered through campaign approaches (e.g., vaccinations, vitamin A supplementation and ITNs), moderate levels of inequality for diarrhea management and antenatal care visits, and large differences favoring wealthier households for the presence of a skilled attendant at delivery. Children in the poorest households were somewhat more likely to be stunted and to die before the age of five years than children in the least poor households. Ethnic diversity within and between the HIDs and comparison area precluded examination of inequities by

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ethnic group membership. When HIDs were compared to the rest of the country, there was no evidence of differences in patterns of health inequalities.

Discussion and interpretation ACSD in Ghana focused available resources on filling gaps in EPI, distributing ITNs, expanding C-IMCI through community health workers and promoting antenatal care interventions. The highest coverage levels in the endline surveys in the HIDs were achieved for vaccinations, vitamin A supplementation to children, antenatal interventions (including IPTp and TT) and ITNs, and most of these interventions progressed faster in the HIDs than in the national comparison area. Exclusive breastfeeding also showed rapid increases in both the HIDs and the comparison area during the ACSD project period. Coverage levels for the correct case management of malaria and diarrhea were low and decreased in the HIDs from before to after ACSD. Taken together, the interventions showing large gains in coverage are likely to have had only limited impact on the main causes of death in Ghana (malaria, neonatal conditions, pneumonia, diarrhea and undernutrition) and hence are consistent with the 20 percent reduction in underfive mortality observed in the HIDs. Interpretation of these findings jointly by the IIP evaluation and Ghana team focused on the missed opportunities for saving further child lives through ACSD, including the need for: 1) greater emphasis on interventions to address child undernutrition; 2) more intensive efforts to change behaviors related to the management of childhood illnesses, skilled delivery and child feeding; 3) greater support and training for the community-based workers that were a key part of intervention delivery; and 4) increased commodity security to ensure adequate and continuous supply of essential commodities. The team also believed that stronger supervision and monitoring systems would have increased ACSD effectiveness. These results must be considered in light of the many international, bilateral and Ghanaian agencies that were active in the HIDs before and concurrent with the ACSD project. Special advantages and contributions of the ACSD project in this complex environment were defined by the implementation team as: 1) the program’s ability to concentrate on a package of effective interventions; 2) the provision of additional resources for commodities, equipment and human resources; 3) clearly stated targets; 4) the establishment of productive partnerships and synergies across institutions; and 5) achievement of strong commitment from the Government of Ghana and other donors. An important methodological issue for this and future evaluations is that the presence of other partners throughout Ghana makes it impossible to attribute observed changes to ACSD alone, and limits the validity of results based on comparisons between the HIDs and broader geographic areas. In summary, the ACSD HIDs accelerated gains in coverage of several key interventions relative to gains in the rest of the country, despite the fact that the HIDs were among the poorest in Ghana and geographically remote. However, several key interventions for reducing the main causes of death in Ghana, showed little change and even some decreases in coverage. While stunting prevalence declined during the ACSD period, there was a similar decline in the remainder of the country from 2003 to 2006. In total, the changes in intervention coverage are consistent with the 20 percent reduction in under-five mortality observed in the HIDs, and compares with what appears to be little or no reduction in the rest of the Ghana.

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Table of Contents 1. The external retrospective evaluation of ACSD in four countries .....................

1

2. Evaluation methods ...........................................................................................

5

3. Characteristics of the “high-impact” districts and comparison area ..................

11

4. ACSD as implemented in Ghana ......................................................................

21

5. Coverage and family practices ..........................................................................

29

6. Nutrition ............................................................................................................

49

7. Mortality .............................................................................................................

55

8. Equity of coverage, nutrition and mortality ......................................................

61

9. Conclusions ......................................................................................................

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References ...............................................................................................................

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Appendices A. Description of Ghana and “high-impact” districts B. Methodology for documentation of implementation activities and contextual factors C. Documentation of implementation D. Definition of key indicators E. Survey Questions F. Methodologies of surveys in Ghana 1998-2007 G. Tables presenting priority coverage indicators over time for ACSD “high-impact” districts H. Tables presenting comparisons of priority coverage indicators over time in ACSD “high-impact” districts and the comparison area I.

Tables presenting 2007 MICS results for key coverage indicators in the ACSD “high-impact” districts by socio-demographic characteristics of the population

J. Additional tables for nutrition K. Methodological challenges L. References for the appendices M. Mapping of partners’ activities in ACSD “high-impact” districts (Upper East region) and nationally

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Acknowledgements This evaluation could not have been conducted without full participation of the representatives from the Ministry of Health, the Ghana Health Services, the Ghana Statistical Service, UNICEF-Ghana and other development partners. We thank them for their commitment to child survival, as reflected in their willingness to share their time, as well as information and their personal opinions about the contributions and limitations of the ACSD project. We specifically would like to thank Eddie Addai and George Amofah from the Ministry of Health and Ghana Health Service who were strong supporters of the evaluation. Vida Abaseka provided valuable information on ACSD implementation; we are grateful to her and the Ghana Health Service team in Upper East region for their dedication and openness to our questions. The Ghana Statistical Service carried out surveys integral to this evaluation; we especially thank Faustina Ainguah and Rochester Appiah for their on-going efforts. Easmon Otupiri at KNUST Department of Community Medicine carried out the program mapping activities, essential to understanding the context in the Upper East region, as well as contributing to the data interpretation. UNICEF-Ghana staff were responsible for working with governments and partners to implement the ACSD project and collaborate in activities related to the independent retrospective evaluation and we thank them for their commitment to child survival and to the evaluation process as a means of improving program effectiveness. We would also like to express our appreciation to Dorothy Rozga, Yasmin Haque, Mark Young, Tamar Schrofer, Victor Ankrah, Bo Pedersen, Elias Massesa, George Fom Ameh, Augustine Botwe, Felicia Mahata and Joanne Greenfield. UNICEF-Ghana also provided financial support for the supplemental survey and advanced technical assistance from Macro, International. This support was essential, as without it there would have been few data to analyze. We would also like to thank UNICEF staff at regional and global levels for their efforts to provide us with documentation about ACSD and the values and conceptual frameworks that guided its implementation. Additionally, we would like to thank the members of the IIP-JHU for their insights and help throughout the evaluation, as well as Macro International and Trevor Croft for technical assistance. Lanie Morgan provided valuable assistance in the documentation of ACSD implementation and contextual factors. Finally, we thank the leadership of UNICEF and CIDA, for their continuing commitment to the importance of independent evaluations and their efforts to see that this work was completed.

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Acronyms ACSD

Accelerated Child Survival & Development Project

ACT

Artemisinin combination therapy for use in treating fever/malaria.

ANC

Antenatal care

ANC+

One of the ACSD intervention packages, consisting of antenatal care and the intermittent prevention of malaria during pregnancy (IPTp)

BASICS

Basic Support for Institutionalizing Child Survival, a project supported by the United States Agency for International Development.

BFHI

Baby Friendly Health Initiative

CBA

Community Based Agent

CDC

US Centers for Disease Control and Prevention

CHW

Community health worker

CHO

Community Health Officer

CHPS

Community-based Health Planning and Services

CIDA

Canadian International Development Agency

C-IMCI

Community component of Integrated Management of Childhood Illness

DANIDA

Danish International Development Agency

DFID

Department for International Development, government of the United Kingdom

DHS

Demographic and Health Surveys (DHS), supported by USAID.

DPT

Diphtheria, Pertussis, Tetanus immunization

EPI

Expanded Programme on Immunization

EPI+

One of the ACSD intervention packages, consisting of the full EPI schedule as well as the provision of vitamin A and deworming twice each year for children aged six to 59 months, and the provision of insecticide-treated nets for the prevention of malaria.

F-IMCI

Facility component of Integrated Management of Childhood Illness, which includes improving the skills of facility-based health workers as well as strengthening aspects of the health system needed to provide appropriate care for children less than five years of age.

GAVI

Global Alliance for Vaccines and Immunizations

GHS

Ghana Health Service

GoG

Government of Ghana

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GoN

Government of the Netherlands

GRCS

Ghana Red Cross Society

GSS

Ghana Statistical Service

Hib

Haemophilus influenzae type b immunization

HIDs

“High-impact” districts for ACSD implementation, defined as Bawku East, Bawku West, Bolgatanga, Bongo, Builsa, and Kasena-Nankana in the Upper East region in Ghana

IEC

Information, Education and Communication

IHNS

Integrated Health and Nutrition Survey in Northern, Upper East, and Upper West Regions of Ghana, 2002

IIP

The Institute for International Programs at JHU

IMCI

Integrated Management of Childhood Illness

IPTi

Intermittent preventative treatment for malaria in infancy

IPTp

Intermittent preventative treatment for malaria in pregnancy

ITN

Insecticide-treated net

JHSPH

The Johns Hopkins University Bloomberg School of Public Health

JICA

Japan International Cooperation Agency

KNUST

Kwame Nkrumah University of Science and Technology

LLITN

Long-lasting insecticide-treated net

MBB

Managing Budgets for Bottlenecks, a tool developed by UNICEF and the World Bank to support results-based planning for maternal, newborn and child survival in developing countries.

MDG

Millennium Development Goal

MDG-4

The fourth millennium development goal, which aims to reduce mortality among children less than five years of age by two-thirds from levels in 1990.

MICS

Multiple Indicator Cluster Survey designed by UNICEF

MOH

Ministry of Health

NGO

Non-governmental organization

NHIS

National Health Insurance Scheme

NIDs

National Immunization Days

ORS

Oral Rehydration Salts, usually pre-packaged in a sachet

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ORT

Oral Rehydration Therapy, can be either pre-packaged in a sachet or prepared in the home

pp

Percentage points

PMTCT

Prevention of mother-to-child transmission of HIV

RHMT

Regional Health management team

SP

A combination of two drugs, sulfadoxine and pyrimethamine. This drug combination is commonly known as Fansidar.

SIA

Supplementary Immunization Activity

SWAp

Sector-Wide Approach: World Bank

TBAs

Traditional Birth Attendants

TT2

Two doses of Tetanus toxoid vaccine during pregnancy

UER

Upper East Region

UNICEF

United Nations Children’s Fund

USAID

United States Agency for International Development

VCT

Voluntary Counseling and Testing

WHO

World Health Organization

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1. The external retrospective evaluation of ACSD in four countries UNICEF implemented the Accelerated Child Survival and Development (ACSD) project between 2002 and 2005 in 11 countries in Africa with support from Canadian CIDA and other partners. The main objective was to use results-based planning techniques to increase coverage with three packages of high-impact interventions known to reduce child mortality (see Box 1). In Benin, Ghana, Mali and Senegal, 16 “high-impact” districts worked to Box 1: deliver all three packages; in the remaining ACSD High-Impact countries, the focus was on the “EPI+” package that included vaccination, Vitamin A and Implementation Packages* insecticide-treated nets (ITNs) for the Immunization plus (EPI+) prevention of malaria. Internal UNICEF evaluations in 2003 and 2004 showed  Routine immunization and periodic measles catch-up and mop-up increases in coverage for the EPI+ package in all countries; UNICEF modeled the associated  Vitamin A supplementation bi-annually reductions in mortality using the "Marginal Budgeting for Bottlenecks " (MBB) tool and  Distribution and promotion of Insecticide Treated Nets for all children who are fully vaccinated as estimated an overall mortality reduction of 20 well as pregnant women, and re-dipping of percent in the “high-impact” districts in the four 1 bednets every six months countries, relative to comparison districts. UNICEF and the evaluation team recognized the limitations of a retrospective evaluation, including the difficulties associated with reconstructing project assumptions and activities on a post hoc basis, and making the best possible use of available data and information despite their shortcomings. Readers are reminded to treat the results with 2 caution.

Improved management of pneumonia, malaria and diarrhea (IMCI+)  Promotion of exclusive breastfeeding for six months, timely complementary feeding



Improved and integrated management (at the health facility, community and family levels) of children suffering from ARI, malaria and diarrhea, including home-based ORS use, treatment of malaria with anti-malarial blisters, and treatment of ARI with antibiotic blisters

The aim of the evaluation is to provide valid and timely evidence to child health planners and policy makers about the effectiveness of ACSD Phase I in reducing child mortality and improving child nutritional status. The specific objectives are:



Promotion of household consumption of iodized salt

1.

To evaluate the impact of ACSD on mortality and nutritional status among children under five.

2.

To document the process and intermediate outcomes of ACSD and resultsbased planning as a basis for improved planning and implementation of child health programs.

Antenatal Care (ANC+)



Intermittent preventive treatment (IPT) of malaria with SP (Fansidar) for pregnant women



Tetanus immunization during pregnancy to prevent maternal & neonatal tetanus



Supplementation with iron/folic acid during pregnancy and with vitamin A post-partum.

______ * UNICEF grouped these interventions into paragraphs in different ways at various points during the project; we have adopted the grouping used in the final report from UNICEF to CIDA for 1 the ACSD project in 2005.

3.

To document the contextual factors necessary for effective implementation of efforts to reduce child mortality in order to be able to extrapolate evaluation findings to other settings.

4.

To assess the process, outcomes and impact of ACSD and results-based planning on socioeconomic, ethnic and gender inequities. Achievement of these objectives should also expand regional and global capacity for large-scale effectiveness evaluations of strategies, programs and interventions designed to improve child health in low-income countries.

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1.1

Evaluation design

Geographic focus: The global retrospective evaluation covers the four countries within which UNICEF defined districts as “high impact” for the ACSD project. Within each country, we focus on these “highimpact” districts (HIDs). Development of a generic impact model for ACSD: The first step in any evaluation is to define what those implementing the project expect to happen because of project activities. We developed an impact model that specifies the pathways through which UNICEF and implementing countries 3 expected ACSD activities to result in reductions in child mortality. Figure 1 presents the generic ACSD impact model in two parts. Figure 1A shows the “top” of the framework describing expected ACSD inputs and processes from the point of introduction at national level in a country through the definition of the three packages of interventions recommended for accelerated implementation (see Box 1 for a description of the three packages). We derived the “top” of the framework from ACSD e.g.4 and discussions with ACSD implementers at all levels. Figure 1B shows the “bottom” documents of the framework, defining the pathways through which each of the three packages was expected to result in reductions in under-five mortality and improvements in the nutritional status of infants and young children. ACSD documents did not describe the pathways in the “bottom” of the model in detail, but made reference to other sources where the effects of the interventions are defined and 5,6 1 quantified. For the internal evaluation, UNICEF utilized the estimates of effectiveness published in these sources and changes in intervention coverage as the basis for modeling the impact of ACSD on child mortality. A central tenet of the evaluation is that the coverage, family practices and impact reflected in the “bottom” of the framework cannot be attributed to ACSD alone. UNICEF and country partners designed ACSD to reinforce existing activities in child survival by the government of each country and its partners. Therefore, increases or decreases in coverage and mortality must be understood as the result of a combined implementation effort, tempered by contextual factors. A key challenge for the current evaluation is to arrive at a qualitative assessment of ACSD’s role as a part of this overall effort; quantified attribution of the results to ACSD alone is not warranted given the implementation approach. Definition of priority indicators for coverage and family practices. Priority coverage indicators address the prevalence of key family practices and intervention coverage for each of the elements defined in the “bottom” of the framework. Although some of these indicators reflect behaviors—such as exclusive breastfeeding and complementary feeding—rather than intervention coverage, these will be referred to as coverage indicators throughout the text. Appendix D defines the priority indicators of coverage utilized in the evaluation. Whenever possible, the ACSD priority coverage indicators are consistent with those supported by a consensus of United Nations (UN) agencies and multi- and bi7,8 Where no international consensus indicator lateral partners for tracking progress toward MDG-4. exists, we contacted technical experts in the topical area to obtain advice on selection of a valid coverage indicator that could be calculated using the data available in Ghana. Definition of priority indicators of impact (nutrition and mortality). The main objective of the ACSD project was to reduce mortality among children less than five years of age. The primary impact indicator in the evaluation is the under-five mortality rate, expressed as the probability of dying between birth and exact age five years. Additional priority indicators include infant and child mortality. Some ACSD project documents described expected improvements in child nutritional status, 9 reflecting the synergy between undernutrition and infectious disease. In Ghana, the regional management team in the HIDs specified ACSD targets to reduce undernutrition by 15 percent in three 10 years and by 25 percent in five years, although specific indicators of undernutrition were not defined. Priority impact indicators include prevalence of stunting, wasting and underweight. Appendix D presents the detailed definitions of the priority indicators for mortality and nutritional status.

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Figure 1B

ACSD impact model: “Bottom” model showing interventions to impact “Top” model showing inputs and processes Antenatal care +

Immunization + DPT, Hib, measles vaccines

Pneumonia

Vitamin A supplementation

Insecticide treated nets

IPT for malaria

Iron/folic acid

Tetanus toxoid

Post-partum Vitamin A

High attendance at facilities/outreach sessions; deployment at community level

High attendance at facilities/outreach sessions

Increased coverage

Increased coverage

Measles

Meningitis / sepsis Diarrhea

Preterm delivery Neural tube defects Neonatal tetanus

Malaria

?????

Spillover effect (co-morbidity)

IMCI +

Improved nutrition Reduced mortality Malaria treatment

ORT

Reduced mortality ? Improved nutrition?

Pneumonia treatment

Breastfeeding promotion

Deployment of interventions at community level

Increased coverage

Malaria

Diarrhea

Pneumonia

Other infections

Spillover effect (co-morbidity)

Reduced mortality Improved nutrition

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Equity. As part of the evaluation, we examine inequity in coverage and impact indicators, including socio-economic status, sex of the child, place of residence (urban or rural) and ethnic groups. Documenting contextual factors. Contextual factors are defined as variables that can confound the association between the delivery of interventions and their health impact, or modify the effects of the 11 We documented contextual indicators in the HIDs and comparison area, including: (1) approach. indicators of implementation-related contextual factors such as characteristics of the health system (e.g., utilization rates), child health policy, drug policy, and availability of drugs; and (2) indicators of impact-related contextual factors including baseline levels and patterns of child morbidity and mortality 11 that can affect the potential magnitude of program impact. Economic evaluation. component.

4

At the request of UNICEF, the evaluation does not include an economic

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2.

Evaluation Methods

2.1

Evaluation design

Overall design. The overall evaluation design was retrospective, drawing on existing population-based surveys with over-sampling of the MICS in the Upper East region, commissioned for the purpose of this evaluation. We re-analyzed pre-existing data sets whenever possible to ensure that the indicator definitions were correct and consistent. Preliminary results were reviewed in meetings of the evaluation team with representatives of the Ghana Health Service (GHS), the Ghana Ministry of Health (MOH), the Ghana statistical service (GSS) and the UNICEF country office in Accra, Ghana in July 2008. Coverage and family practice indicators. We reanalyzed existing household survey data to calculate the ACSD priority coverage and family practice indicators. As described above, these indicators are consistent with those used 7,8 internationally for monitoring progress toward the Millennium Development Goals and are presented in appendix D. Appendix E provides the specific survey questions used for the indicator calculations. Nutrition and mortality indicators. We reanalyzed existing household surveys to calculate the priority nutrition indicators using the 2006 12 Appendix J and section 6 present more details on these methods. For WHO Growth Standards. calculation of priority mortality indicators, the evaluation team analyzed mortality retrospectively, using direct under-five mortality estimates based on full birth histories collected in the 2007 MICS supplemental survey in the HIDs. Estimates of under-five mortality in the comparison area were based on available direct and indirect estimates. Intervention area. The intervention area included the Upper East region (UER), selected for ACSD “high-impact” implementation. When ACSD was first implemented, the Upper East region comprised six districts: Bawku East, Bawku West, Bolgatanga, Bongo, Builsa, and Kasena-Nankana. In 2005, new health districts and boundaries were defined, these eight districts in Upper East region are: Bawku Municipality, Bolgatanga Municipality, Bongo, Builsa, Bawku West, Kasena-Nankana, Guru Tempane and Talensi Nabdam (Figure 3). Throughout the body of this report and appendices, we refer to the six “high-impact” districts (HIDs) defined at the inception of ACSD, unless otherwise noted. Comparison area. The main comparison area is the remainder of Ghana excluding the urban areas of Greater Accra and Ashanti regions (Accra and Kumasi). We have excluded Accra and Kumasi because access to services and living conditions in these areas differ considerably from the predominantly rural HIDs. Intervention activities. We documented the timing and scale of intervention activities using information collected from field visits to the HIDs, key informant interviews and document review, such as administrative and supervision reports and monitoring data. Equity. To examine inequities, we performed analyses of selected intervention coverage and impact measures stratified by sub-groups of the population, including household assets (expressed in quintiles), sex of the child, place of residence (urban/rural) and ethnic group. Contextual factors. We collected standard information on contextual factors, defined above, in order to assist in interpretation of the results and the potential contributions of ACSD. Certain elements, such as economic status, ethnicity and access to clean water were re-analyzed for HIDs and comparison areas using existing household survey data. Field visits to the HIDs, key informant interviews and

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document review provided contextual information not available in existing surveys. A program mapping exercise, carried out by investigators at Kwame Nkrumah University of Science and Technology (KNUST), documented health and development activities in the HIDs and nationally between 1999 and 2007. Appendix B and M provide further details on the methods used to collect contextual factors.

2.2

Data sources and methods

Tables 1a and 1b summarize the different types of information used in the evaluation. The 1998-9 and 2003 Demographic Health Surveys (DHS) and the 2006 Multiple Indicator Cluster Survey (MICS) with a supplemental survey in the Upper East region (HIDs) conducted in 2007 served as the primary data sources for estimates of intervention coverage and nutrition in the HIDs and comparison area. For estimation of the endline coverage and nutrition results in the HIDs, we utilized the Supplemental MICS 2007; the 2006 national MICS was utilized to provide endline estimates in the comparison area, excluding the HIDs and urban areas of Greater Accra and Ashanti regions. We did not merge the MICS 2006 data for the HIDs with the supplemental MICS 2007 data due to incompatible sampling strategies and the small sample size of the data in the HIDs (Upper East region) in the 2006 MICS. The 2007 supplemental MICS included a full-birth history module used to estimate child mortality both before and after ACSD implementation. The full-birth history method allows the calculation of period estimates of mortality ranging from the previous 12 months to 10 or more years in the past. No comparable data was available for the comparison area. Estimation of under-five mortality in the comparison area was based on indirect child mortality estimation as measured in the DHS 2003 and MICS 2006, and direct estimates from DHS 2003. Section 7 describes the mortality analysis methods in more detail. Other survey data were available, but given lesser prominence in the analyses because they did not fully meet the quality criteria established for the evaluation. These criteria were: 1) full data sets and documentation, including sampling weights, available to the evaluation team so that the data could be reanalyzed using the standard definitions for priority indicators; and 2) no more than 5 percent missing values on key socio-demographic variables (e.g., child age) or the variables needed to construct the priority indicators. We did not use data from the Integrated Health and Nutrition Survey (IHNS) 2002 and the CDC-ACSD 2003 survey in the primary analyses because they did not fulfill these criteria. However, we use these data to explore time trends between 1998-9 and 2006-7. Descriptions of the methodology and conduct of surveys used in the evaluation are presented in appendix F and full documentation of 2003 ACSD-CDC survey data quality issues is available upon request from IIP-JHU evaluation team. Table 1b presents sources of information used in the documentation of intervention activities and contextual factors. We collected information through: 1) review of documents, including administrative and monitoring reports; 2) key informant interviews; and 3) searches and review of published and grey literature. Technical staff at UNICEF-Ghana provided input and revisions throughout the process of documentation. Due to the retrospective nature of the evaluation, it was difficult to collect complete and standardized information on ACSD implementation activities and other health activities in the Upper East region. The collaborative nature of ACSD makes it difficult to distinguish which activities were: 1) carried out as part of the ACSD program, 2) carried out with only partial technical and/or financial support from the ACSD program, or 3) carried out by ACSD partners, but independent of the ACSD program. In some cases, the information presented in administrative reports was inconsistent; for example, annual reporting of the number of bednets treated varied slightly. Appendix C notes observed discrepancies in implementation reports.

6

IIP-JHU | Retrospective evaluation of ACSD in Ghana

Table 1a: Data sources for independent retrospective evaluation of ACSD in Ghana, populationbased surveys.

TYPE OF DATA

DESCRIPTION

USE IN EVALUATION

Populationbased surveys that met inclusion criteria

DHS 1998/1999: Nationally representative household survey conducted from November to February 1999.

Used to establish baseline levels of priority coverage and nutrition indicators in HIDs and comparison area.

DHS 2003: Nationally representative household survey conducted from July to October 2003.

Used to estimate interim coverage and nutrition indicators in HIDs and comparison area.

MICS 2006: Nationally representative household survey conducted from August to November 2006.

Used to estimate priority coverage and nutrition indicators in HIDs and comparison area.

MICS supplemental 2007: Household survey in Northern, Upper West and Upper East region conducted from September to December 2007 with additional EA’s collected in February 2008.

Used to estimate endline coverage and nutrition indicators in HIDs. Used for retrospective estimation of mortality in HIDs.

IHNS 2002: The Integrated Health and Nutrition Survey in Northern, Upper East, and Upper West regions conducted from February to March 2002.

Reported in appendices, but given limited weight in analysis due to availability of a usable datafile.

CDC-ACSD 2003: Household survey of 2341 households in the Upper East region carried out from July to September 2003.

Reported, but given limited weight in analysis due to concerns about data quality.

Other populationbased surveys

IIP-JHU | Retrospective evaluation of ACSD in Ghana

7

Table 1b: Data sources for independent retrospective evaluation of ACSD in Ghana, routine data, administrative reports and key informant interviews.

TYPE OF DATA

DESCRIPTION OF KEY DOCUMENTS

USE IN EVALUATION

Routine health information system data

Routine data collected through health facilities pertaining to intervention coverage, compiled at the local, regional and national levels.

Documentation of MOH and ACSD activities.

Administrative reports

Annual UNICEF reports: Three administrative reports from 2003 – 2005 detailing implementation and inputs; ACSD annual reports and presentations – Upper East region: Eight reports/presentations on ACSD progress 2004 - 2006, one EPI+ report 2004; Ghana Health Service: Upper East region Health Sector Annual Reviews: 2000 – 2006;

Documentation of ACSD and partners’ activities.

Bawku West annual reports: five health sector update reports: 2004 – 2006; IMCI training/monitoring reports: Nine documents prepared by the regional offices and KNUST.

8

Job aids and tools

Job aids and tools, such as visual aids and register books, used in the implementation of ACSD were collected and reviewed where possible.

Summary report

UNICEF Assessment of ACSD, 2004.

Program mapping of development activities in UER and nationally

KNUST contracted to perform sub-study on partner activities in UER and nationally; (Appendix M presents the full methods and sources list).

Key informant interviews

Approximately 24 interviews at the national, regional and district level: see appendix B for summary.

Documentation of ACSD activities and contextual factors.

Working discussions

Field visit and discussions: November 2006; Review of preliminary results: July 2008.

Discussion and documentation of ACSD activities and contextual factors.

Documentation of ACSD and partners’ activities. Documentation of ACSD activities.

Documentation of contextual factors.

IIP-JHU | Retrospective evaluation of ACSD in Ghana

2.3

Analysis

13

We employed the Habicht et al framework for real-life evaluations. Starting with an adequacy evaluation, we assessed whether trends in coverage indicators were moving in the expected direction, and whether goals were met. Next, we carried out a plausibility evaluation, defined as a controlled, non-randomized study that assesses whether observed impact can be attributed to program implementation. ACSD in Ghana was a combination of separate interventions – vaccines, mosquito nets, vitamin A supplementation, etc – that are highly efficacious if delivered at optimal coverage. The evaluation did not assess the efficacy of these interventions, but instead focused on their impact when delivered under routine conditions. We carried out the analysis of coverage and nutrition in four steps, explained below. Section 7 describes the analysis of under-five mortality.

Step 1: Generating indicator levels for each survey in the analysis Objective: To describe levels of priority indicators for coverage and nutrition in all surveys included in the analysis, overall and for specific subsets of children defined by age, sex, geographic location of the household, mothers’ education and socioeconomic status, where sample sizes permit. We applied standard indicator definitions to the reanalysis of all datasets to ensure the comparability of indicators over different surveys. For each indicator, only data for women and children with known responses for that indicator were included in the analyses; cases with missing or unknown data were excluded. The point estimates of indicators presented here may therefore differ slightly from those calculated using standard DHS and MICS tabulation programs, which do not exclude missing records from the analyses. Step 2: Comparing rates of change over time within each ACSD district (“time trends”). Objective: To determine whether there are statistically significant differences in indicator levels within HIDs from before ACSD was implemented to after ACSD was implemented in ACSD areas, with a mid-point during the process of implementation where adequate data are available, overall and for specific subsets of children. This step refers to the adequacy evaluation. Step 3: Comparing rates of change between ACSD and non-ACSD districts within each country (“time trend with comparison”). Objective: To determine whether there are statistically significant differences in the rates of change for indicator levels between the HIDs and comparison area where ACSD was not implemented (the comparison area is comprised of the rest of Ghana, excluding Accra, Kumasi and the HIDs), overall and for specific subsets of children. Step 4: Attributing improvements to ACSD and related child survival activities at country level. Objective: To determine whether any statistically significant changes in indicator levels can be attributed to ACSD activities, including activities implemented by others in collaboration with ACSD and the national child survival plan, overall and for specific subsets of children. Steps 3 and 4 refer to the plausibility evaluation, assessing whether progress was greater in the ACSD than in the comparison area, and whether or not external factors can account for these differences. For all comparisons across time and geography, we initially calculated a simple chi-square statistic of difference. The simple chi-square statistic does not take into account the design effect of the survey, thus it under-estimates the variance. If no statistical differences were observed using the simple chisquare statistic, we assumed that none would be observed after the design effect was taken into consideration (adding to the variance) and that the groups were therefore not statistically different from one another. For comparisons with a significant chi-square, we calculated standard errors and 95 percent confidence intervals that take into account the survey design effect, using the Taylor Linearized Variance method. We used a “difference-in-differences” approach to compare whether the change in each indicator over time differed significantly between the HIDs and comparison area.

IIP-JHU | Retrospective evaluation of ACSD in Ghana

9

10

IIP-JHU | Retrospective evaluation of ACSD in Ghana

3. Characteristics of the “high-impact” districts and comparison area This section presents pertinent characteristics of Ghana as a whole and the HIDs and the comparison area. We emphasize differences between the HIDs and comparison area, as well as factors that have changed over the evaluation period to help guide the interpretation of evaluation results. Some of the quantitative results (table 2) presented here are based on our reanalyses of available survey data, because these provide the most recent information disaggregated by the HID and comparison area. Appendices A and M present additional information on the geographic, socio-demographic, economic, health and health service factors in Ghana and the UER.

3.1

Figure 2: Map of Ghana and its neighbors

The Ghana context

Ghana, located in West Africa, maintains three international boarders and a coast off the Gulf of Guinea (Figure 2). Togo is situated to the East, Cote d’Ivoire to the West, and Burkina Faso to the North and Northwest. Great Britain established a colony in 1874 known as the Gold Coast, and Ghana declared independence in 1957. The first president of Ghana, Dr. Kwame 17 Nkrumah was overthrown in a military coup in 1966. A cession of military leaders ruled Ghana until Jerry Rawlings seized power in 1981 and gradually restored civilian rule, with the first free elections in 17 1992. The current president John Agyekum Kufor holds office in his second and final term ending in December 2008. 18

The Of Ghana’s estimated 23 million population, 38 percent are younger than 15 years old. estimated growth rate is currently 1.9 percent with a total fertility rate of 3.8 19 births per woman. In 2000, 41 percent Box 2: 19 Wellof the population was urban. Overview of child health in Ghana endowed with natural resources, Ghana’s per capita output is twice that Causes of under-five deaths in Ghana* of neighboring West African countries. Despite prosperity relative to its Pneumonia Malaria 15% 27% neighbors, Ghana maintains a 5.7 billion 33% (US$) debt, 26 percent of the Gross Injuries 3% National Income. According to a new Ghana Living Standards Survey reported by the World Bank, poverty levels have dropped from 52 to 29 HIV/AIDS 6% percent between 1992 and 2005.

3.2

Measles 3%

Child health in Ghana

Diarrhea 12%

Neonatal 29%

1990

2006

Mortality rates (per 1000 live births)** Under-five

120

Infant

120 76

Prevalence of undernutrition*** Stunting (% mod + severe)

28

Underweight (% mod + severe)

13

14

15

16

Sources: *WHO, 2006 ; **SOWC ; ***MICS 2006

IIP-JHU | Retrospective evaluation of ACSD in Ghana

Ghana had an estimated population of 3.2 million children under age five in 2006. The under-five mortality rate has stagnated at 120 per 1000 live births between 1990 and 2006, falling short of progress needed to achieve the twothirds reduction from 1990 levels defined by the fourth Milliennium Goal (40 per 1000 live births). Box 2 shows the major causes of under-five deaths in Ghana in 14 Almost 2003 as reported by WHO one-third of all under-five deaths occur in the neonatal period. Among these deaths, infections account for

11

approximately one-third (32%) with the remainder attributed to preterm births (26%), asphyxia (23%), congenital (6%) tetanus (4%) and other causes (9%). Child undernutrition is also a problem in Ghana. In 2006, estimates using the new WHO growth standards indicated that 28 percent of children under five years of age were either moderately or severely stunted, 6 percent were wasted, 20 and 13 percent were underweight. Appendix A includes the full profile of maternal, newborn and 20 child health from the Countdown to 2015 2008 report.

3.3

Selection of the ACSD “high-impact” districts in Ghana

UNICEF and the Government of Ghana Figure 3: Map of eight health districts, as (GoG) selected the six districts in the of 2005, Upper East region, Ghana Bawku Mun. Upper East region (UER) for “highimpact” implementation of ACSD. UER Kassena/Nankana Bongo is one of the poorest regions in Ghana and had high levels of under-five Bawku Bolgatanga M. mortality, contributing to its choice for West GaruTempane implementation of the ACSD approach. Talensi-Nabdam UNICEF had been supporting activities in the Bawku West and Builsa districts Builsa in the UER since 1995; the ACSD “high-impact” districts (HIDs) included these two districts as well as the remaining four districts in the UER. Redistricting occurred in 2005 and the UER is now comprised eight districts (Figure 3). Key informants reported that other factors considered in the choice of the UER included: 1) political stability; 2) a strong regional health team; and 3) a passable road network, ensuring high accessibility to the entire region.

3.4

Socio-economic and demographic factors

Figure 4 shows the incidence of poverty in the HIDs and the geographic comparison area as 21 measured in the 2000 Housing and Population Census and the Ghana Living Standards Survey 4. The poorest districts are located in the northern areas of the country, with the six HIDs, noted in the call-out box, among the poorest in the country. Table 2 presents socio-demographic variables as measured in household surveys in 1998-9, 2003 and 2006-7 in the HIDs and comparison area. Based on our re-analyses of the DHS 1998-9, DHS 2003 and MICS 2006-7, households in the HIDs remained significantly poorer relative to the comparison area throughout the evaluation period (p24 CASES]

Percentage of children aged 0-59 months with diarrhoea receiving ORS, RHF or increased fluids and continued feeding

Percentage of children aged 0-59 months with suspected pneumonia taken to an appropriate health provider Percentage of children aged 0-59 months with suspected pneumonia treated with antibiotics

chloroquine

0

Ghana antimalarial policy

78

%

No data

60

n

Miss( 95% %) CI

1998/1999 DHS

Percentage of children aged 0-59 months with fever receiving appropriate 3 antimalarial drugs

Percentage of children aged 0-59 months with fever receiving antimalarial 2 drugs

IMCI case management indicators

Table G2. Illness case management indicators over time in the “high impact” districts, Ghana (weighted)

IIP-JHU | Retrospective evaluation of ACSD in Ghana

A49

39

39

19

13

Percentage of newborns put to the breast within one hour of birth

Percentage of infants aged 0-5 months who are exclusively breastfed

Percentage of infants aged 6-9 months who are breastfed and receive complementary food

Percentage of children aged 20-23 months who are currently breastfeeding n/a

n/a

[28]

11

%

n/a

n/a

3

0

n/a

n/a

n/a

3-19

n

33

%

2002 IHNS¹

21

18

28

45

n

n/a

n/a

[43]

85

%

n/a

n/a

0

0

miss( %)

2003 DHS

n/a

n/a

n/a

73 97

95% CI

93

94

168

328

n

82

50

39

45

%

8

5

3

2

miss( %)

2003 ACSDCDC

25

30

32

28

n

[92]

[53]

[56]

42

%

0

0

0

0

miss( %)

2006 MICS²

n/a

n/a

n/a

2955

95% CI

(2) MICS 2006: NO FULL BIRTH HISTORY; UNABLE TO CALCULATE BREASTFEEDING INDICATORS AS DHS (SEE APP.D)

[UNWEIGHTED: BASED ON CASES 25-49] [N/A: RESULTS NOT SHOWN; BASED ON >24 CASES] (1) IHNS DATA NOT AVAILABLE; INDICATORS FROM IHNS 2002

n

Indicators

miss( 95% CI %)

1998/1999 DHS

Table G3. Feeding behaviour indicators over time in the “high impact” districts, Ghana (weighted)

125

159

258

484

n

84

53

55

52

%

0

0

0

0.8

miss( %)

77 92

42 63

46 64

47 56

95% CI

2007 MICS suppl²

A50

IIP-JHU | Retrospective evaluation of ACSD in Ghana

1

45

19

72

39

39 0

0

61-83

10-27

7-27 47

1

17

46-79

39

0

18

20

45

45

0

0

0

2

47-70

5-34

10-30

332

332

281

51

No data

27

10

74

322 4065

56

320

1947

5

74

82

%

No data

318

326

326

n

0-10

0-10

50 78

5898

95% CI

24 CASES]

Percentage of households consuming iodized salt (>=15ppm) (exclude HH with no salt)

Percentage of households consuming iodized salt (>=15ppm)

Percentage of infants aged 6-9 months who are breastfed and receive complementary food Percentage of children aged 2023 months who are currently breastfeeding

Percentage of infants aged 0-5 months who are exclusively breastfed

Percentage of newborns put to the breast within one hour of birth

IMCI feeding behavior indicators

HID

1998/1999 DHS

, Table H3. Feeding behaviour indicators over time in “high impact” districts and comparison areas, Ghana (weighted)

A72

IIP-JHU | Retrospective evaluation of ACSD in Ghana 63

509

508

508

0.7

23

38

38

0

0.1

0.2

No data

No data

46

33

4

4

64

78

%

45 45 45

33 42 19 27

44

58

20

18

52

No data

45

45

33 43

41 51

45

50 59 45

45

61 70

n

HID

566

664

566

506

562

542

542

552

552

0.6

4

4

2

2

36

35

35

33

0

0.4

0

11

No data

47

1

1

58

76

32 - 40

31 - 40

30 - 40

29 - 38

43 - 51

0-1

0-2

54 - 63

72 - 80

Comparison area ¥ Miss( n % %) 95% CI

2003 DHS

78

63

67

82

81

89

%

40

481

531

533

529

531

500

500

532

532

(1)Women with institutional deliveries assumed to have appropriate postnatal care (2) Skilled health worker defined as Doctor, nurse/midwife or auxilliary midwife

57

No data

485

No data

482

484

479

480

478

478

n

1

0

48

36 - 48

70 - 79

0.5 43 - 53

No data

42

26 37

37 - 48

0.5 55 - 65

6

6

0.3 61 - 71

0.3 76 - 84

No data

75

60

31

43

66

80

Comparison area ¥ 2006 MICS Miss( n % %) 95% CI

2006 MICS/ 2007 MICS suppl. HID 2007 MICS suppl

¥ COMPARISON AREA IS GHANA – NATIONAL LEVEL, EXCLUDING THE UER AND THE MAJOR METROPOLITAN AREAS OF ACCRA AND KUMASI

72

19

39 39

17

39

Percentage of births attended by skilled health worker ² Percentage of newborns receiving a postnatal visit by a skilled health worker within 3 days of delivery¹ ²

Percentage of women receiving vitamin A supplementation within 2 months of birth

No data

No data

39

505

1

No data

55

1

No data

505

66

No data

64

39

505

Comparison area ¥ Miss( 95% n % %) CI

No data

74

%

39

n

Percentage of pregnant women receiving 3 months of iron supplementation.

Percentage of newborns fully protected against tetanus

Percentage of newborns protected against tetanus (2+ doses TT during pregnancy)

Percentage of pregnant women who report at least 3 prenatal visits to a skilled health worker ² Percentage of pregnant women who report at least 4 prenatal visits to a skilled health worker ² Percentage of pregnant women receiving intermittent preventative treatment for malaria during pregnancy in previous year (any SP) Percentage of pregnant women receiving intermittent preventative treatment for malaria during pregnancy in previous year (2+ SP)

ANC, assisted delivery and postnatal care indicators

HID

1998/1999 DHS

Table H4: Antenatal delivery and postnatal care indicators over time in “high impact” districts and comparison areas, Ghana (weighted)

IIP-JHU | Retrospective evaluation of ACSD in Ghana

A73

21%

10%

12%

22%

78%

Bawku Municipality

Talensi-Nabdam

Garu-Tempane Residence

Urban

Rural

Total

10%

Bawku West

8 Residence

412

3324

2580

58% 21% 21%

None Primary Secondary + Total

7% 0.1%

Yes Not sure Education

3288

674

702

1911

3

229

914

28

25 cases; [unweighted] - >50 cases in at least one cell

25%

27%

Total

435

24%

2

455

1145

25%

1120

1380

399

184

24%

29%

26%

12-23

24-59

419

1846

male

9%

31%

0-5

6-11

Rural

206

376

female Wealth index quintiles Poorest

Gender

Age in months

22%

26%

Urban

Garu-Tempane

Residence

30%

33%

Talensi-Nabdam

591

226

22%

22%

Bawku West

Bawku Municipality

102

198

16%

25%

Bongo

Bolgatanga Municipality

295

272

30%

17%

Builsa

Kasena-Nankana

Districts

% with fever

Number of Number of % given any children 0antichildren 059m with 59m* malarial fever¹

Children 0-59 with fever in previous 2 weeks

2268

429

474

473

457

435

1146

1122

1382

399

185

302

1848

420

377

206

591

226

199

103

272

295

Number of children 059m*

41%

42%

39%

56%

29%

37%

39%

43%

[47%]

[41%]

[41%]

[14%]

42%

33%

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

ORS (%)

47%

43%

51%

62%

36%

40%

45%

48%

[54%]

[46%]

[41%]

[21%]

48%

37%

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

ORS + RHF (%)

74%

73%

74%

79%

77%

68%

74%

74%

[81%]

[74%]

[69%]

[50%]

75%

69%

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

28%

32%

32%

30%

28%

19%

34%

23%

[32%]

[26%]

[28%]

[14%]

27%

32%

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

357

67

66

79

74

71

174

183

195

93

39

29

299

58

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

ORS/ RHF/ Number of ORS/ RHF/ increased fluids children 0increased with continued 59m with fluids (%) feeding (%) diarrhoea¹

Children 0-59 with diarrhoea in previous 2 weeks

Table I5: Illness case management by socio-demographic characteristics in “high-impact” districts, Ghana 2007-8

Care management of fever, suspected pneumonia, and diarrhea for children 0-59 months with illness in the previous 2 weeks

A78

IIP-JHU | Retrospective evaluation of ACSD in Ghana

28%

2%

9%

15%

2%

1%

6%

1%

3% 3%

3% 9%

66%

9%

64%

0% 0%

53%

61%

71%

67%

Any AM treatment

²Children under five with non-missing data for indicator calculation: weighted

¹ Appropriate antimalarial treatment defined as Mali policy for first line malaria treatment (CQ in 1998-9 & 2003; ACT in 2006 & 2007-8)

NOTE: Anti-malarial treatment columns are not mutually exclusive

High Impact districts

1%

1%

National comparison

MICS 2007/2008

66%

High Impact districts MICS 2006 43%

64%

0% 0%

Data not available

High Impact districts DHS 2003

National comparison

Data not available

Children with a fever in the last two weeks who were treated with: ACT/ Appropriate Chloroquine Amodiaquine Quinine CoArtem AM¹

National comparison

DHS 1998/1999

SP/ Fansidar

554

602

44

518

No. of children with fever in last two weeks²

Table I6: Treatments given for fever in the 2 weeks preceding the survey in “high-impact” districts and comparison areas over time, Ghana 2007-8

IIP-JHU | Retrospective evaluation of ACSD in Ghana

A79

6% n/a 5%

34% n/a 28%

National comparison

National comparison

12%

0%

28% n/a

0% n/a

0%

23%

0% n/a

20% n/a

Private sector drug vendor Village Health worker

¹Children under five with non-missing data for indicator calculation: weighted

High Impact districts 46% Note: Mutally exclusive in order of table

MICS 2007/2008

High Impact districts MICS 2006

3%

5% n/a

High Impact districts DHS 2003

16% n/a

Private Health center / facility

National comparison

DHS 1998/1999

Public health center / facility

2%

1%

1% n/a

4% n/a

Other

Children with suspected pneumonia in the last two weeks who were taken to:

36%

44%

31% n/a

55% n/a

145

158

279 n/a

336 n/a

Number of Not treated / children aged 0treated at home 59 months with / neighbors pneumonia¹

Table I7: Locations where care was sought for suspected pneumonia in the 2 weeks preceding the survey in “high-impact” districts and comparison areas over time, Ghana 2007-8

A80

IIP-JHU | Retrospective evaluation of ACSD in Ghana

[53%] [41%] [55%]

Bawku Municipality

Talensi-Nabdam

Garu-Tempane

52%

47%

Least Poor

93

484

97

91

95

108

55%

[79%]

[62%]

[52%]

[45%]

[55%]

55%

54%

80% 33%

[54%]

[75%]

[53%]

[53%]

[37%]

[49%]

n/a

[72%]

[73%]

[58%]

Exclusively breastfeed

258

42

52

46

62

58

144

115

120 138

216

44

36

32

38

37

24

32

30

31

Number of children 0-5m²

n/a - small sample size >25 cases; [unweighted] - >50 cases in at least one cell

¹Women with a live birth in previous 12 months with non-missing data for indicator analysis: weighted ² Children with non-missing data for indicator analysis: weighted

Total

57% 60%

3 4

50% 44%

-

-

2

-

-

male

256

228

390

94

82

56

73

62

42

61

46

60

female

47% 56%

0-2

3-5

Poorest

Wealth index quintiles

Sex

Age in months

42%

[45%]

Bawku West

54%

[43%]

Bolgatanga Municipality

Rural

[66%]

Bongo

Urban

[50%]

Kasena-Nankana

Residence

[57%]

Builsa

Districts

Timely Birth within initiation of previous 12m¹ breastfeeding

53%

[38%]

[67%]

[50%]

[62%]

[49%]

53%

159

29

27

34

34

33

79

80

-

52%

-

-

131

26

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

Number of children 69m²

-

[52%]

[58%]

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

Complementary feeding

84%

n/a

n/a

n/a

n/a

n/a

[85%]

[83%]

-

-

[87%]

[74%]

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

Continued breastfeeding

125

n/a

n/a

n/a

n/a

n/a

73

47

-

-

93

27

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

Number of children 2023m²

Timely initiation of breastfeeding, exclusive breastfeeding among children 0-5 months, complementary feeding among

Table I8: Prevalence of infant feeding behaviours as reported by mothers by socio-demographic characteristics in “high-impact” districts, Ghana 2007-8

IIP-JHU | Retrospective evaluation of ACSD in Ghana

A81

[69%[ [82%]

Talensi-Nabdam

Garu-Tempane

83% 76% 84%

Mother's education level None

Primary School

Secondary school+

82%

79%

Least Poor 67%

71%

69%

69%

67%

56%

70%

63%

67%

70%

63%

66%

70%

[67%]

[59%]

[68%]

[58%]

[73%]

[53%]

[74%]

[69%]

2+

487

96

93

92

107

91

60

103

316

252

227

387

92

81

54

72

62

41

60

46

61

Birth within previous 12m¹

63%

66%

68%

70%

56%

53%

64%

61%

63%

61%

65%

62%

68%

[51%]

[59%]

[74%]

[68%]

[76%]

[67%]

[72%]

[34%]

TT2

78%

83%

80%

85%

70%

71%

84%

74%

77%

80%

75%

76%

83%

[68%]

[66%]

[90%]

[84%]

[91%]

[75%]

[89%]

[51%]

Full TT

Neonatal tetanus protection

484

97

93

93

107

93

62

104

318

256

228

390

94

61 47 61 42 62 72 56 81

Birth within previous 12m¹

n/a - small sample size >25 cases; [unweighted] - >50 cases in at least one cell

¹ Women with a live birth in previous 12 months with non-missing data for indicator analysis: weighted

Total

89% 86%

3

2 4

73% 81%

Poorest

Wealth index quintiles

79% 84%

0-5

6-11

Months since birth

84%

[85%]

Bawku Municipality

81%

[82%]

Bawku West

Rural

[93%]

Bolgatanga Municipality

Urban

[60%]

Bongo

Residence

[80%] [89%]

Kasena-Nankana

1+

Builsa

Districts

IPT during pregnancy

89%

96%

91%

92%

84%

84%

94%

92%

88%

87%

92%

88%

81%

93%

83%

80%

75%

75%

89%

83%

79%

79%

84%

80%

85%

[73%]

[83%] 94%

[75%]

[84%]

[83%]

[89%]

[94%] [93%]

[83%]

[77%]

[87%] [86%]

[94%]

[74%]

4+

[100%]

[84%]

3+

Prenatal visits with a trained health care worker

478

96

92

92

107

92

62

103

313

254

224

385

94

73

75

83

62

42

60

46

61

Birth within previous 12m¹

Antenatal care (including IPT, TT, Fe) among women who have given birth in the previous 12 months

Table I9: Antenatal care indicators among women giving birth within the previous 12 months by socio-demographic characteristics in “high-impact” districts, Ghana 2007-8

A82

IIP-JHU | Retrospective evaluation of ACSD in Ghana

[43%] [34%] [33%]

Bawku Municipality

Talensi-Nabdam

Garu-Tempane

38% 65%

Primary School

Secondary school+

29% 46% 77%

3

4

Least Poor 40%

27%

2

485

97

93

95

107

93

62

104

319

256

230

392

94

81

56

73

62

42

61

47

61

Birth within previous 12m²

95 481

57%

92

94

108

93

60

104

318

255

226

389

92

82

56

72

60

41

61

47

60

Birth within previous 12m²

60%

58%

62%

51%

52%

63%

60%

54%

56%

57%

54%

66%

[51%]

[63%]

[58%]

[60%]

[63%]

[43%]

[55%]

[55%]

Postnatal supplementation with Vitamin A

n/a - small sample size >25 cases; [unweighted] - >50 cases in at least one cell

²Women with a live birth in previous 12 months with non-missing data for indicator analysis: weighted

¹Trained health care worker: doctor, nurse/midwife or auxilliary midwife

Total

23%

Poorest

Wealth index quintiles

36%

Mother's education level None

46% 35%

0-5

6-11

Months since birth

33%

[37%]

Bawku West

71%

[55%]

Bolgatanga Municipality

Rural

[46%]

Bongo

Urban

[45%]

Residence

[36%]

Builsa

Kasena-Nankana

Districts

Skilled birth attendant ¹

Delivery and postnatal care indicators among women who have given birth in

Table I10: Assisted delivery and post-natal care among women giving birth in the previous 12 months by socio-demographic characteristics in “high-impact” districts, Ghana 2007-8

IIP-JHU | Retrospective evaluation of ACSD in Ghana

A83

4% 2% 4%

National comparison

High Impact districts MICS 2006

National comparison 37%

36%

11%

29%

13%

17%

Nurse/midwife

0%

2%

4%

1%

3%

17%

Aux. midwife

1%

0%

0%

0%

0%

0%

24%

37%

20%

40%

71%

47%

Traditional birth attendant¹

² No assistance or assisted by friend/relative ³ Women with a birth in previous 12m with non-missing data for indicator calculation: weighted

Note: Chart mutually exclusive in order of doctor to no assistance ¹ Trainied or untrained TBA

High Impact districts

2%

1%

High Impact districts DHS 2003

MICS 2007/2008

4%

National comparison

DHS 1998/1999

Doctor

Community health worker

Delivery assisted by:

35%

21%

63%

25%

12%

15%

No assistance²

485

533

45

566

39

508

Birth within previous 12m³

Table I11: Health providers assisting deliveries in “high-impact” districts and comparison areas over time, Ghana 2007-8

APPENDIX J Additional tables for nutrition Figure J1: Protocol for inclusion and exclusion of cases for nutrition analyses in “high-impact” districts and national comparison as measured in 1998 DHS, Ghana

Excluded: National comparison

1998 Total Number of children under five

n=2612

13%

n=199 Incomplete result

Wt/Ht 4% outliers

5%

A84

Excluded: High impact districts

11%

Wt/Ht 3% outliers

Unknown DOB

0.6%

Ht/age 4% outliers

Ht/age 5% outliers

Wt/age 1% outliers

Wt/age 2% outliers

IIP-JHU | Retrospective evaluation of ACSD in Ghana

Figure J2: Protocol for inclusion and exclusion of cases for nutrition analyses in “highimpact”districts and national comparison as measured in 2003 DHS, Ghana

Excluded: National comparison

2003 Total Number of children under five

n=2834 3%

12%

4%

n=241 Did not sleep in household last night

4%

Non-biological children

15%

Incomplete result

25%

Wt/Ht 4% outliers