Over the last three decades, Ghana has invested large amounts of effort in implementing various strategies to reduce maternal and child mortality in the country.

1. EminentPanelConference,Accra,August7th -9th,2020
PRELIMINARY FINDINGS:
Health Systems Strengthening
Patrick Opoku Asuming,
University of Ghana Business School

2. What is a health system?
• A health system “consists of all the organizations, institutions,
resources and people whose primary purpose is to improve health”
(WHO 2010)
- Encompasses both direct and indirect efforts to improve health
- Preventive, promotive, curative & rehabilitative care in pyramids of health
facilities
• Key functions of a health system
- Service delivery, resource generation, financing and stewardship
• The WHO framework identifies 6 pillars of the health system
- Service delivery, health workforce, health information systems
- Access to essential medicines, financing, leadership & governance

3. Importance of Health Systems
• Several health interventions in Ghana over the last two decades have
improved health outcomes
- However gains have not been universal, broad-based or sustainable
• A key reason for this
- Interventions are vertical and not fully integrated into the overall health
system
• Mounting evidence that health systems better deliver efficient,
equitable and sustainable improvement in health outcomes (

4. Child Mortality: Uneven progress

5. Health Systems Intervention 1
Emergency Obstetric and Neonatal Care (EmONC)

6. Scaling up of EmONC
• Upgrading of existing facilities to provide comprehensive EmONC
services
- Facilities must be able to provide all 9 EmONC signal functions
- Scaling existing facilities by providing required equipment, medicines &
essential EmONC supplies
- Training & Capacity Strengthening of existing clinical & non-clinical staff
• Scaling up 79 existing facilities to provide comprehensive EmONC
services throughout Ghana
- 79 represent only 1/6 of the required facilities based on a 2011 EmONC survey

7. Cost: Scaling-up of 79 facilities will cost GHS 836m by 2032
Costs = 836 million cedi
• Equipment would be replaced every 5 years
- 94m initially, 155m by 2032
• New constructions built at start
- Requires 57m upfront cost
• Recurrent costs of staffing, operations and
consumables
- 48m cedi increasing with real GDP growth to 79m
by 2032
• Small amount of training cost incurred every 3 years
• Costs based on a detailed costing study from 6
facilities in Tanzania
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GHS
millions
Cost of scaling up EmONC in 79 facilities
Recurrent Buildings Equipment Training

8. Benefits: Scaling up EmONC will reduce intrapartum neonatal
mortality by 27%
BCR = 5.6
Benefits = GHS 4.6 billion
• Reduces intrapartum neonatal mortality
by 27% for births conducted in a facility
- Based on Gabrysch et al. (2019)’s assessment
of impact of EmONC in Ghana
• Boosts facility births by 10% after first
year
• Approx. 400-500 avoided deaths per year
to 2032
• Does NOT include maternal deaths
(important but likely contributes little to
overall benefit)
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Newborn deaths averted due to intervention
Initial boost because having
EmONC facilities increases
facility births by 10% after
the first year – this
increases the amount of
influence-able deaths

9. Health Systems Intervention 2
NEWborn Health INTervention Study (NEWHINTS)

10. NEWHINTS Intervention
• Deployment of Community-Based Service Volunteers (CBSVs)
• Original intervention based on a large-scale RCT in Brong Ahafo region
• Visits to provide counseling-based help during pregnancy to neonatal
stage
• $5 monthly stipend to CBSVs
• CBSVs trained and provided logistics to provide 5 visits from early
pregnancy to 7 days post delivery
- Counseling on ANC visits, dangers signs, use of bednets, delivery in facilities,
breastfeeding, assessing babies for danger signs
• We model scaling intervention to cover 100% of Ghana’s rural
population

11. Costs: Home visits during pregnancy and birth for 410,000
women would cost 25m cedi per year
Total Costs = 25m cedi per year
Target population
• 410,000 women in rural Ghana
who give birth every year
• Cost per mother is 61 cedi
• Roughly two thirds of cost is for
staff time
• Inexpensive because the key
driver of the intervention is
community health worker
activity
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GHS
millions
Annual cost of home visits
Staff costs Maternal time Capital expenditure Supplies Other

12. Benefits: NEWHINTS will reduce neonatal mortality by 8%
Total Benefits = GHS 698.2 million
• Modest reduction in neonatal mortality – 8%
- This translates into 819 neonatal deaths averted per year
- Mortality reduction benefit of GHS 667.9 million
• To account for morbidity benefits, we estimate an additional 2%
reduction in mortality
- Additional GHS 30.3 million
• Effect based on randomized control trial from Ghana
• BCR = 28

13. Health Systems Intervention 3
Ghana Essential Health Interventions Programme (GEHIP)

14. GEHIP Intervention
• GEHIP intervened along all six pillars of WHO health System building
blocks
- Construction of new CHPS+ compounds, development on rural referral system,
supply non-medical equipment (motobikes, tricycles and bicycles, etc), new
electronic data collation at district level,
- Training of district and subdistrict directors on use of data for resource use,
training of health personnel on basic EmONC
• GEHIP interventions implemented over a three-year period in four
predominantly rural districts in Upper East region
• We model scaling up GEHIP to cover entire rural population of Ghana

15. Cost: GEHIP will cost GHS 160m over a 6-year period
Target population
• 12.6 million rural population
Costs = 160m cedis
• Assumption is that the
intervention will be implemented
over six years
• Large initial investment required
in the first year
• Ongoing costs 17% of first year
costs
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GHS
millions
Cost profile over time (6 years)

16. Benefits: GEHIP generates benefits worth GHS 6.1 billion
BCR = 38
Benefits = GHS 6.1 billion
Neonatal mortality avoided
• 12% reduction in neonatal mortality in
first year rising to 23% by year 3, then
falling after that
Other benefits
• 25% reduction in diarrhea
- 106,634 diarrhoea cases prevented in first year then
declining after that
• 37% reduction in malaria
- 373,034 malaria cases prevented in first year then
declining
1,152
1,233
2,136
1,183
1,069
523
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500
1,000
1,500
2,000
2,500
Deaths
avoided
Neonatal deaths avoided over time

17. Summary of BCRs
INTERVENTION Benefits
(GHS million)
Cost
(GHS million)
BCR
EmONC 4,647 836 5.6
NEWHINTS 698 25 28
GEHIP 6,149 160 38