MDG ACCELERATION FRAMEWORK AND COUNTRY ACTION PLAN

GHANA

MDG ACCELERATION FRAMEWORK

AND COUNTRY ACTION PLAN

MATERNAL HEALTH

July 2011

18605 Ghana omslag.indd 1 25/05/11 00.30

MDG ACCELERATION FRAMEWORK

AND COUNTRY ACTION PLA

MATERNAL HEALTH

July 2011

Country Team in the Republic of Ghana

Acknowledgements:

The Ministry of Health, Ghana Health Service and the UNDP wishes to express

its appreciation to the task team and all who in diverse ways worked tirelessly to

develop the MDG Acceleration Framework Country Action Plan. Members of the

task team involved in the preparation of the action plan include:

George K. Amofah, Deputy Director General, Ghana Health Service; Patrick Kuma-

Aboagye, Deputy Director, RCH, Ghana Health Service; Kyei-Faried, Deputy Director,

DCD, Ghana Health Service; Pa Lamin Beyai, Economic Advisor, UNDP; Akua Dua-

Agyeman, MDG Support Advisor, UNDP; Siaka Coulibaly, MDG Advisor, RSC UNDP,

Dakar; Daniela Gregr, Policy Specialist, UNDP; Ayodele Odusola, MDG Advisor,

UNDP; Shantanu Mukherjee, Policy Advisor, UNDP; Robert Mensah, NPO-RH, UNFPA;

Rhoda Manu, PMTCT-MH Specialist, UNICEF; Charles Fleischer-Djoleto, NPO-FHP,

WHO; Joseph Adomako, DDHS-Amansie West District, Ghana Health Service. We

are grateful to the consultants Alhaj Mohammed Bin Ibrahim and Moses Aikins for

their hard work in guiding the development of this document.

Design:

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Cover photo credits:

UNDP Kayla Keenan

18605 Ghana omslag.indd 2 25/05/11 00.30

JULY 2011

GHANA

MDG ACCELERATION FRAMEWORK

UNTRY ACTION PLAN

MATERNAL HEALTH

ACKNOWLEDGEMENTS .......................................................... 2

ABBREVIATIONS ................................................................ 8

FOREWORD ..................................................................... 10

CHAPTER 1 INTRODUCTION.................................................... 12

CHAPTER 2 PROGRESS AND CHALLENGES IN ACHIEVING MDG 5................. 22

GHAPTER 3 STRATEGIC INTERVENTIONS ………………………………………....... 40

CHAPTER 4 BOTTLENECK ANALYSIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

CHAPTER 5 ACCELERATING MDG PROGRESS: IDENTIFYING SOLUTIONS.......... 52

CHAPTER 6 MDG ACCELERATION PLAN: BUILDING A COMPACT.................. 62

6.1 COUNTRY ACTION PLAN ............................................... 63

6.2 IMPLEMENTATION AND MONITORING PLAN............................ 72

ANNEXES ....................................................................... 80

ANNEX 1 POLICY DOCUMENTS AND REPORTS....................................... 81

ANNEX 2 QUESTIONNAIRE ADMINISTERED TO DDHS GROUP ........................ 82

ANNEX 3 MDG 5 DOCUMENTS, RECOMMENDATIONS AND LEVEL OF

IMPLEMENTATION.......................................................... 84

ANNEX 4 REFERENCES ............................................................... 87

CONTENTS

TABLE 1. HEALTH BUDGET 20062009.....................................................26

TABLE 2. TOTAL CONTRACEPTIVES FUNDING REQUIREMENTS BY PROGRAM, 20102012..30

TABLE 3. STATUS OF MDGS AND TRENDS TOWARDS ACHIEVING THEM ...................32

TABLE 4. HUMAN RESOURCE REQUIREMENTS 2010 AND STATUS AS OF 2007, GHANA ..43

TABLE 5. SUMMARY MATRIX OF KEY PRIORITY INTERVENTIONS AND INDICATIVE

INTERVENTIONS, GHANA ........................................................45

TABLE 6. SUMMARY TABLE OF BOTTLENECKS TO KEY PRIORITY INTERVENTIONS TO

ACHIEVE MDG 5 TARGETS, GHANA ...............................................49

TABLE 7. PRIORITIZED SOLUTIONS FOR ACCELERATING PROGRESS TOWARDS

MDG 5, GHANA ..................................................................56

TABLE 8. GHANA MDG 5 ACCELERATION ACTION PLAN ...................................64

TABLE 9. GHANA MDG 5 IMPLEMENTATION AND MONITORING PLAN.....................72

TABLES

FIGURE 1. TRENDS IN MATERNAL MORTALITY .............................................24

FIGURE 2. MAP OF INSTITUTIONAL MATERNAL MORTALITY RATIO IN GHANA BY REGION . 25

FIGURE 3. SELECTED INDICATORS OF REPRODUCTIVE HEALTH CARE, 19882008 .........27

FIGURE 4. POSTNATAL CARE COVERAGE...................................................28

FIGURE 5. FAMILY PLANNING ACCEPTOR RATE BY REGION, 20072009 ....................29

FIGURE 6. DEMAND FOR FAMILY PLANNING AMONG CURRENTLY MARRIED WOMEN .....29

FIGURE 7. VARIATIONS IN CHPS DEPLOYMENT TARGETING ................................31

FIGURES

ABBREVIATIONS

ANC Antenatal Care

BCC Behavioural Change Communication

BEOC Basic Emergency Obstetric Care

BTS Blood Transfusion Service

CENC Comprehensive Essential Neonatal Care

CEOC Comprehensive emergency obstetric care

CHPS Community Health Planning and Service

CSO Civil Society Organization

DAs District Assemblies

DHIMS District Health Information Management System

DHMT District Health Management Team

ENC Essential Neonatal Care

EmONC Emergency Obstetric and Neonatal Care

FP Family Planning

GAVI Global Alliance for Vaccines and Immunizations

GDP Gross Domestic Product

GHS Ghana Health Service

GNP Gross National Product

GPRS I Ghana Poverty Reduction Strategy I

GPRS II Growth and Poverty Reduction Strategy II

GNP Gross National Product

HIRD High Impact Rapid Delivery

HIV/AIDS Human Immunodeﬁciency Virus/ Acquired Immune Deﬁciency Syndrome

ICC Inter-Agency Coordinating Committee

IEC Information, Education and Communication

IUD Intrauterine Device

LSS Life Saving Skills

MAF MDG Accelerated Framework

MDG Millennium Development Goals

MDRI Multilateral Debt Relief Initiative

MMDAs Metropolitan, Municipal and District Assemblies

MoFEP Ministry of Finance and Economic Planning

MoH Ministry of Health

MoWH Ministry of Works and Housing

MNH Maternal and Neonatal Health

MMR Maternal Mortality Rate

NDPC National Development Planning Commission

NGO Non-Governmental Organization

NHIS National Health Insurance Scheme

PDA Personal Data Assistant

PMTCT/CT Prevention of Mother to Child Transmission/Counselling and Testing

PNC Postnatal Care

SD Skilled Delivery

STI Sexually Transmitted Infection

TOR Terms of Reference

UNAIDS Joint United Nations Programme on HIV/AIDS

UNCT United Nations Country Team

UNFPA United Nations Population Fund

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

WHO World Health Organization

WB World Bank

“The Millennium Development Goals (MDGs) are

achievable by 2015, if supported by the right set of

policies, targeted technical assistance, institutional

capacity, adequate funding and strong political

commitment. The Government of Ghana, in

collaboration with its development partners, is fully

committed to achieving the MDGs by 2015.

Recent experiences in Ghana demonstrate that

success is possible and that evidence-based eﬀective

interventions can be identiﬁed for realizing the

MDGs. Nevertheless, although progress has been

satisfactory in MDGs 1, 2, 3, 6 and 8, it has been

less in other areas, MDGs 4, 5 and parts of 7. At the

current pace of progress, Ghana may not meet the

MDG target by 2015 with business as usual. The

present MDG Acceleration Compact capitalizes

on the existing commitment and captures the

evidence available to put forward concrete and

realistic proposals to scale up the achievement of

the MDGs in the next ﬁve years…”

This MDG Acceleration Framework (MAF) – Ghana

Action Plan was developed by the Ministry of

Health and Ghana Health Service in collaboration

with development partners particularly the United

Nations Country Team and other stakeholders in

Ghana. The focus of the Action Plan is on MDG

5 because the progress in reducing the maternal

mortality ratio by three quarters by 2015 is off

track. The 2010 MDG Report showed the maternal

mortality rate to be at 451 per 100,000 live births. The

slow progress has been of great concern to policy

decision makers to the extent that Maternal Mortality

was declared a national emergency in July 2008.

Therefore, the main reason for this MAF is to redouble

eﬀorts to overcome bottlenecks in implementing

interventions that have proven to have worked in

reducing the maternal mortality ratio in Ghana. The

MAF focuses on improving maternal health at the

level of both community and health care facilities

through the use of evidence-based, feasible and

cost-effective interventions in order to achieve

accelerated reduction in maternal and newborn

deaths. The three key priority interventions areas

identiﬁed are improving family planning, skilled

delivery and emergency obstetric and newborn care.

At the health facility level, emphasis is placed

on the creation of an enabling environment,

including equipment and supplies, for well-trained

professionals to attend to pregnancy, childbirth

and the newborn. The community level focuses on

FOREWORD

equipping communities with knowledge and skills

to enable them to adopt good health practices and

better health-seeking behaviour and to recognize

danger signs related to pregnancy and childbirth

as well as with the newborn. This document takes

cognizance of the inseparable dyad of the mother

and the newborn as well as the interrelationships

among all the eight MDGs.

The MAF is not aimed at replacing existing

interventions. Rather, it is meant to complement

them with speciﬁc focused interventions for the

achievement of MDG 5 by 2015. To achieve that,

the Ghana MAF cannot be the business of the

government alone, but requires the support of UN

agencies, other development partners and CSOs to

better understand the deep-rooted causes militating

against positive outcomes in maternal health care

and collectively work towards overcoming them.

Once the CAP is implemented with the support of all

stakeholders, Ghana will reduce the risks of maternal

deaths and once again be on track to achieving

MDG 5 by 2015.

The declaration of His Excellency Professor John

Evans Atta Mills, President of the Republic of Ghana at

the recent African Union Heads of State Conference

in Kampala, Uganda, that “no woman should die

while giving life” is a vision that the implementation

of this Action Plan seeks people to support it

through resource mobilization, implementation

and Monitoring and Evaluation.

Minister of Health, Ghana

Hon. Dr. Benjamin Kunbuor

UN Resident Coordinator

Ruby Sandhu-Rojon

1212

Making initial plans

and establishing baselines

STAGE 1:

INTRODUCTION

Photo: Kayla Keenan

CHAPTER 1:

1.1: BACKGROUND

Ghana, a tropical country on the west coast of Africa,

is divided into 10 administrative regions and 170

decentralized districts. The country has an estimated

population of about 23.4 million (GSS, 2009) with a

population density varying from 897 per km

in the

Greater Accra Region to 31 per km

in the Northern

Region. Life expectancy is estimated at 56 years for

men and 57 years for women, while the adult lit-

eracy rate (age 15 and above) stands at 65 percent.

The government is a presidential democracy with

an elected parliament and independent judiciary.

The principal religions are Christianity, Islam and

Traditional African. Ghana’s economy has a domi-

nant agricultural sector (small-scale peasant farm-

ing) absorbing 55.8 percent (GLSS 5) of the adult

labour force, a small capital intensive mining sector

and a growing informal sector (small traders and

artisans, technicians and businessmen). Since in-

dependence, Ghana has made major progress in

economic growth. However, a number of questions

arise as to how to accelerate equitable growth and

sustainable human development towards attaining

middle-income country status by 2015.

At the turn of the century, in September 2000, Ghana,

along with 189 UN member countries adopted the

Millennium Declaration that laid out the vision for a

world of common values and renewed determination

to achieve peace and decent standards of living for

every man, woman and child. The eight Millennium

Development Goals (MDGs) derived from the Millen-

nium Declaration set time-bound and quantiﬁable

indicators and targets aimed at halving the proportion

of people living below the poverty line, improving ac-

cess to primary education, promoting gender equality,

reducing child mortality, improving maternal health,

combating and reversing the trends of HIV/AIDS,

malaria and other diseases, ensuring environmental

sustainability, and promoting global partnership for

development between developed and developing

countries by 2015. This set of eight clear, measurable

and time bound development goals were expected

to generate unprecedented, coordinated action, not

only within the United Nations system, including the

Bretton Woods institutions, but also within the wider

donor community and, most importantly, within de-

veloping countries themselves.

Ghana has since mainstreamed the MDGs into the

country’s successive medium-term national develop-

ment policy framework, the Ghana Poverty Reduc-

tion Strategy (GPRS I), 2003 – 2005, and the Growth

and Poverty Reduction Strategy (GPRS II), 2006–2009.

The GPRS I focuses on macroeconomic stability, pro-

duction and gainful employment, human resource

development and the provision of basic services to

the vulnerable and excluded, and good governance;

GPRS II emphasizes continued macroeconomic sta-

bility, human resource development, private sector

competitiveness, and good governance and civic

responsibility. Within the same period of the two

development policy frameworks, Ghana beneﬁted

from the Highly Indebted Poor Country (HIPC) initia-

tive and other international development assistance

support programmes including the Multilateral Debt

Relief Initiative (MDRI), Multi-Donor Budget Support

(MDBS) and the United States-funded Millennium

Challenge Account programme, among others.

In addition to direct poverty reduction expenditures,

government expenditure outlays were also directed

at policies and programmes to stimulate growth,

which have high potential to support wealth crea-

tion and sustainable poverty reduction.

Total poverty reduction expenditure as a percentage

of total government spending declined from 34.56

percent in 2006 to 22.82 percent in 2007 and further

down to 22.3 percent in 2008 (2008 APR). In terms

of sector shares, the largest share of total poverty

spending went to basic education, which accounted

for 41.42 percent in 2007 and 47.24 percent in 2008.

This was followed by health sector spending at 19.5

percent in 2007 and 18.05 percent in 2008. Expendi-

ture on rural electriﬁcation, water supply and feeder

roads ranged from 1.57 percent to 7.23 percent in

2007 and 1.36 percent to 5.04 percent in 2008. Such

declines in poverty spending have implications for

the achievement of the MDGs despite the country

being on track to achieve poverty and related targets

which form the focus of subsequent discussions.

1.2 OVERALL PROGRESS IN

ACHIEVING THE MDGS IN GHANA

According to the 2010 MDG Report, Ghana’s progress

in achieving the MDGs is mixed. The country is

largely on track to achieve the MDG 1 target of

reducing by half the proportion of the popula-

tion living in extreme poverty. The overall poverty

rate has declined substantially over the past two

decades from 51.7 percent in 1991–1992 to 28.5

percent in 2005–2006 while the proportion of the

population living below the extreme poverty line

also declined from 36.5 percent to 18.2 percent over

the same period against the 2015 national target of

26 percent and 19 percent respectively. Although

current data on poverty is not available, trends

in economic growth suggest a further decline in

poverty between 2006 and 2008. However, de-

spite the signiﬁcant decline in poverty at the national

level, regional, occupational and gender disparities

exist. Some regions did not record improvements

in poverty, particularly the three Northern regions

where high levels of poverty persist. Over 70 percent

of people whose incomes are below the poverty line

live in the Savannah areas. The 2009 Human Develop-

ment Report (HDR) shows Ghana’s Human Develop-

ment Index (HDI) rank had declined and inequality

remained high. Thus the high growth rate has not

necessarily been consistent with improved human

development indicators as the country continues to

face challenges in health and other social services.

With regard to MDG 1 Target 1C, halving the propor-

tion of people who suﬀer from hunger, Ghana is on

course to achieving the child malnutrition indicators

ahead of 2015. The prevalence of children suﬀer-

ing from wasting and stunting that characterized

the late nineties continued to be reversed in 2008.

The incidence of wasting has declined from a peak

level of 14 percent in 1993 to 5.3 percent in 2008,

while the occurrence of underweight children has

declined from about 23 percent in 1988 to 13.9 per-

cent in 2008. In terms of districts facing chronic food

production deﬁcits, the trend has seen continuous

reduction from 22 in 2005 to 15 in 2006, and further

down to 12 in 2008. These achievements were made

possible as a result of numerous programmes and

interventions implemented by government, includ-

ing fertilizer subsidies and the expanded maize and

rice programmes which supported farmers with

agricultural inputs (fertilizers, improved seeds), and

subsidies to meet ploughing and labour costs.

Available data and trend analyses of MDG 2 —

achieving universal primary education — show

that Ghana is on track to achieving both the

gross and net enrolment targets by 2015. The

number of schools and enrolment rates have in-

creased tremendously over the years due to various

reforms and new policy measures instituted by the

government. The number of kindergarten schools

has increased from 14,246 in 2006–2007 to 15,449

in 2007–2008 following the government’s policy of

mandating each primary school to have a kindergar-

ten attached to it. The Gross Enrolment Ratio (GER)

for kindergarten has subsequently increased from 89

percent in 2006–2007 to 89.9 percent in 2007–2008.

The number of primary schools rose from 16,903 in

2006–2007 to 17,315 in 2007–2008, while the GER

increased from 93.7 percent to 95.2 percent over the

same period. The area where challenges exist is the

survival rate which has stagnated at 88 percent in

2007–2008 from 85.4 percent in 2006–2007.

With regard to the MDG 3 target of ensuring gen-

der parity especially at the primary and junior

high school levels, trends show that Ghana is on

track to achieving both targets, although prima-

ry level parity has stagnated at 0.96 since 2006-

–2007, while the parity at the junior high school

level increased slightly from 0.91 in 2006—2007

to 0.92 in 2007–2008. On the other hand, the parity

at the kindergarten level has declined slightly from

0.99 in 2006–2007 to 0.98 in 2007–2008. Progress to-

wards increasing the number of women in public life

suﬀered a setback with the reduction of the number

of women elected into parliament during the 2008

elections declining from 25 to 20. This had reduced

the proportion to below 10 percent, and puts Ghana

under the international average of 13 percent.

Although evidence shows that there has been

signicant reduction in both infant and under-

ve mortality rates in Ghana, it is unlikely that

the 2015 target of reducing the child mortality

rates will be easily met. The Ghana Demographic

and Health Survey (GDHS) 2008 showed a 30 per-

cent reduction in the under-ﬁve mortality rate, as

it declined from 111 per 1,000 live births in 2003

to 80 per 1,000 live births in 2008, while the infant

mortality rate in 2008 stood at 50 per 1,000 live births

compared to 64 per 1,000 live births in 2003. The

neonatal mortality rate also saw a decrease from

43 per 1,000 live births in 2003 to 30 per 1,000 live

births in 2008. The proportion of children aged 12

to 23 months who received the measles vaccine

increased from 83 percent in 2003 to 90 percent in

2008, showing an improvement in coverage in one

of the key child survival interventions (MoH, 2008;

GHS, 2003).

The key child health interventions are antenatal care

(ANC), delivery care, postnatal care, immunization,

nutrition, management of childhood illnesses and

malaria prevention. In the last decade some progress

has been made to improve child survival. Household

ownership of insecticide-treated nets has improved

to 61.6 percent (urban) and 66 percent (rural) areas,

immunization coverage is high (Penta3 87 percent,

see GHS 2008

), National Health Insurance Scheme

(NHIS) coverage is high, antimalaria combination

therapy is universally available and infant and child

mortality have declined (see GSS 2008

; MICS

Maternal health care has improved over the past

20 years albeit at a slow pace. Between 1990 and

2005, maternal mortality ratio reduced from 740

per 100,000 live births to 503 per 100,000 live

births, and then to 451 per 100,000 live births

in 2008. If the current trends continue, maternal

mortality will be reduced to only 340 per 100,000 by

2015, instead of the MDG target of 185 per 100,000

by 2015. The improvement, however, is not the same

for all regions. There are disparities in the institutional

maternal mortality rate (MMR) across the 10 regions

in Ghana from 1992 to 2008 in the Northern and

Western Regions; 120.1 per 100,000 in Volta and the

Eastern Regions; and 59.7 per 100,000 in the Upper

West, Brong Ahafo and Ashanti regions. The only

region where the ratio has worsened is in Greater

Accra (by 87.6 per 100,000). Maternal death was

declared notiﬁable within seven days in Ghana in

January 2006 and the notiﬁcation rate in 2007 was

71.8 percent. A quarter (75.4 percent) of 751 maternal

deaths in Ghana (2007) were audited.

After a decline from a high of 3.2 percent in 2006

to a low of 2.2 percent in 2008, evidence from

the 2009 Sentinel surveillance report suggests

an increase in the HIV/AIDS prevalence rate in

Ghana to 2.9 percent in 2009. According to the

Ghana AIDS Commission, the current up-and-

down movement in the prevalence rate between

2003 and 2008 signals a leveling eect or stabi-

lization of the epidemic.

On MDG 7 – ensuring environmental sustainabil-

ity – Ghana is on track to achieve the target of

halving the proportion of people without access

to safe water. Critical challenges exist in achieving

the targets for reversing the loss of environmental

resources, reducing the proportion of people with-

out access to improved sanitation, and achieving

signiﬁcant improvement in the lives of people living

in slum areas. Although up-to-date data on the rate

of forest depletion is unavailable, evidence suggests

that the country is depleting its forest cover at an

alarming rate. Between 1990 and 2005, the forest

cover declined from 32.7 percent to 24.2 percent.

While access to safe water services in rural areas

has improved considerably, there has been slow

progress on access to safe water within urban areas.

Even though Ghana has made progress in reducing

the proportion of the population without access to

improved sanitation, the target may not be achieved

by 2015 if the current trends continue. If the current

trend is maintained, the proportion of the population

with access to improved sanitation will reach 21.2

percent by 2015 instead of 52 percent. The propor-

tion of the urban population with access to improved

sanitation will be 23.4 percent instead of 55 percent

by 2015, while in the rural areas, it would be only

20.6 percent instead of 50.5 percent. Also, though

the proportion of urban population living in slums

shows a decline, if the current pattern continues, a

signiﬁcant proportion (about 14 percent) will still be

living in slum areas by 2020.

In terms of global partnerships for development,

many developed countries have not met the 0.7

percent GNP target for aid. However, aid inﬂows to

Ghana appear to have increased in nominal terms

from $578.96 million in 2001 to $1,433.23 million

in 2008. The current concern, however, is the level

1) GHS, Disease Control and Prevention Department 2008 Annual report.

2) GSS, Demographic and Health Survey 2008.

3) MoH, Multiple Indicator Cluster Survey (MICS) 2006.

of increases in real terms and the quality of the aid

the country receives. In real terms, ODA inﬂows to

Ghana have stagnated at about 8.7 percent of GDP

between 2002 and 2008, after an initial rise from

6 percent of GDP in 1999 to 15 percent of GDP in

2001. The portfolio of aid inﬂows continued to be

dominated by project aid, which constitutes more

than 60 percent of ODA inﬂows. The global ﬁnancial,

oil and food crisis appear to have impacted nega-

tively on the public debt position of Ghana, which is

gradually approaching unsustainable levels. Ghana’s

public debt as a percentage of GDP increased from

41.4 percent in 2006 to 55.2 percent in 2008.

1.3: Past and emerging

challenges and their impact on

achieving the MDGs

The global food and energy crisis, as well as the

eﬀect of the global economic crisis and the presi-

dential and parliamentary elections between 2006

and 2008 adversely aﬀected pro-poor expenditures.

While the debt relief fund for Highly Indebted Poor

Countries continued to fund activities in support of

both poverty reduction and growth enhancement,

the Multilateral Debt Relief Initiative(MDRI) which

came into eﬀect in 2006 addressed the energy crisis

as well.

Prior to the onset of the ﬁnancial crisis, foreign in-

ﬂows (export earnings, investment and remittances)

were buoyant. In the beginning of 2009, however,

the country recorded a budget deﬁcit of 14.5 percent

of GDP excluding divestiture receipts, and 11.5 per-

cent of GDP including divestiture receipts; as well as a

large current account deﬁcit of 20.87 percent of GDP.

The country faced a high base interest rate of 27.22

percent and an average annual inﬂation of 18.13

percent in 2008. Average depreciation recorded was

20.6 percent and 16.1 percent against the US dol-

lar and the Euro, respectively. Ghana’s high level of

dependence on the world economy, with as much

as 30 percent of budget support from international

partners, and her strong trade links with the US and

Europe, may imply that any disturbance emanating

from the international ﬁnancial system is bound to

have an eﬀect on the domestic economy. In terms of

international trade and foreign direct investment, the

global ﬁnancial crisis does not show to have created

a major setback as far as Ghana is concerned. Gold

and cocoa, Ghana’s main exports, were resilient in

the face of the crisis and as a result of investments

in the oil and gas ﬁelds, foreign direct investment

has increased. It cannot therefore be argued that

developments in international trade and FDI nega-

tively aﬀected the achievement of any of the MDGs

in Ghana. However, the crisis brought with it negative

consequences for the ﬁnancial markets. Banks have

been reluctant to provide credit to households, to

small and medium enterprises (SMEs) as well as to

big businesses, for fear of loan defaults. In addition,

discount, interest, prime and lending rates have in-

creased. As far as the stock market is concerned, the

all-share index fell drastically and trade volume has

also decreased. These developments have aﬀected

share prices paid to clients which may have further

aﬀected incomes of households.

The impact of climate change is now more than

ever before being felt. There is clear evidence that

the potential negative impacts of climate change

are immense, and Ghana is particularly vulnerable

due to its lack of capacity to undertake adaptive

measures to address environmental problems and

the socio-economic costs of climate change (EPA,

2000). For instance, in agricultural areas, particularly

in the central and northern regions of the country,

climate change has contributed to the deterioration

of rural livelihoods, reﬂected in declining incomes,

malnutrition and hunger. The ﬂooding of coastal

areas, which are already undergoing erosion, and low

operating water levels of the only hydro-generating

dam in the country are further problems. The vul-

nerability of people to daily shocks and stresses is

intrinsically tied to the human adaptive capacity —

and strategies created — to respond to ﬂoods, high

temperatures, coastal erosion, rises in the sea level,

and other climate-related events. Climate change

is likely to exacerbate these shocks and stresses,

particularly among the poorest and most vulnerable

populations and, therefore, may inhibit the attain-

ment of the MDGs. The evidence of the implications

of these phenomena for the attainment of the MDGs

in Ghana may have been underreported. It is impor-

tant that this is given the needed attention since

it has the potential of not only eroding the gains

already made, but also pf frustrating eﬀorts being

made to achieve the goals.

1.4: THE MAF, CAP AND

OBJECTIVES

Various studies have indicated that globally achiev-

ing MDG 5 is oﬀ track and is not likely to be achieved

in many countries, Ghana included, as both targets

for measuring progress appear not to have been

reached so far. A number of reviews have been made,

challenges to implementation identiﬁed and various

recommendations made. The number of policy

documents, strategic plans and review reports on

maternal health and reducing maternal mortality

is very impressive. But implementation has almost

always stalled, leading to minimal impact on the

MMR. In the opinion of one of our development

partners, “Many action plans, initiatives and working

groups exist in Ghana to tackle MDG 5. We know

the speciﬁc interventions required to achieve MDG

5 — these are well detailed in the various plans and

initiatives. Several of these initiatives have been fully

costed, so we even have a sense of the resources

required. We do not require another action plan

specifying what interventions to carry out, nor do we

need another analysis of why maternal mortality is

high in Ghana.” He goes on to indicate that “what we

need is why the speciﬁc interventions have not been

implemented”. Unfortunately, these recommenda-

tions for implementing the proposed interventions

and overcoming identiﬁed bottlenecks are scattered

in many documents, making it diﬃcult to monitor

the progress of implementation. As we approach

the target year of 2015, all the identiﬁed bottlenecks,

recommendations and action plans scattered in the

various documents need to be brought together to

help understand why the known speciﬁc interven-

tions were not implemented.

The MAF, introduced by the UN System, falls in line

with the concerns and priorities of the Government

of Ghana. Thus the selection of Ghana along with 10

countries (four in Africa — Ghana, Tanzania, Togo and

Uganda) to develop a Country Action Plan (CAP) or

the acceleration of MDG 5, which is oﬀ track. MDG 5

is not likely to be attained by 2015 if eﬀorts are not

redoubled. The Ghana CAP contains the elaboration

of the key prioritized interventions that are required

to achieve MDG 5, identiﬁes the bottlenecks to the

interventions and suggests cost-eﬀective solutions

to address the bottlenecks and accelerate progress.

The CAP includes an implementation and monitor-

ing plan for tracking progress. This is expected to

enable Ghana to address the critical constraints that

hamper the progress towards achieving MDG5 and

put maternal mortality target back on track by 2015.

1.4.1: MAF objectives

The MAF aims at supporting national governments,

UN agencies and other development partners and

civil society organizations ( CSOs) working in the

MDG areas to better understand the key causes af-

fecting positive outcomes in a particular MDG, ﬁnd

key solutions and develop an action plan that can

help to reduce the risks hampering progress of that

MDG. In the case of Ghana, the MAF objectives

seek to:

• reviewexistingpoliciesandinterventionsinthe

area of MDG 5 i.e., maternal health care;

• identifythekeybottleneckstotheimplementa-

tion and attainment of MDG 5;

• identifygapsinexistingpoliciesandinterventions;

• developcost-eectivesolutionsthatcanacceler-

ate progress towards the attainment of MDG 5;

• designanactionplanforimplementingtheindica-

tive interventions and monitor progress.

1.4.2: Methodology used in

preparing the MAF CAP

An interactive and participatory approach was

adopted for the MAF roll-out. A National Technical

Team was established and two resource persons

were recruited to manage day-to-day activities. A

desk review of national policy documents, reports

and roadmaps was undertaken covering 30 national

reports on maternal health care delivery and 37 Na-

tional Policy Documents. To ﬁll in the information

gaps, focus group discussions and rapid survey ques-

tionnaires to District Directors of Health Services

were also carried out. Consultative meetings of the

technical team were organized to review the initial

ﬁndings (in terms of interventions and bottlenecks)

and answer the question: Why have the speciﬁc

interventions not been implemented? The key inter-

ventions, bottlenecks and solutions were prioritized

using the method of ranking (high/medium/low)

and selection criteria (impact, sustainability, speed,

resources). Based on the ﬁndings, the technical team

worked during workshops and consultations to de-

velop the draft CAP.

1.4.3: MAF consultative process

The process of the MAF roll-out, including the prepa-

ration of the CAP, was nationally driven, interactive

and participatory, and carried out under the overall

leadership of the MoH. Ownership was further en-

hanced by engaging multiple stakeholders drawn

from key sector ministries, CSOs, the UN Country

Team (UNCT) and development partners involved

in supporting maternal health care interventions.

Stages for the MAF roll-out and preparation of the

CAP were as follows:

A UNDP-led consensus building and introduction

of the MAF with the key government sector, MoH,

which in turn led to close consultation with key UN

agencies (WHO, UNICEF, UNFPA, UNDP) to establish

an inter-agency National Technical Team. The Minis-

try of Health(MoH) and UN agencies identiﬁed the

MAF as timely and in line with their eﬀorts to ﬁnding

a solution to the high maternal mortality in Ghana.

• AnationalproposalontheMAFroll-outwasde-

veloped and Ghana entered into a collaboration

with the global UNDP MAF team for ﬁnancial,

technical and advisory support for the process.

• TheGovernmentofGhanaorganizedanincep-

tion meeting with selected partners including

the UNCT and agreed on the methodology and

identiﬁed bottlenecks for analysis, and reviewed

and adopted the action plan for MAF implementa-

tion.

• ANationalTechnicalTeamthatcomprisedthe

MoH, UNICEF, UNFPA, WHO and UNDP was es-

tablished by the MoH to support the MAF roll-

out. While the specialized UN agencies provided

technical inputs, UNDP played a coordinating role

and provided quality assurance.

• Twonationalconsultantswererecruitedtofurther

support the Technical Team and manage the day-

to-day process of the MAF roll-out.

• Initialactivitiesinvolved(i)adeskreviewofNa-

tional Policy Documents, reports and roadmaps

(30 national reports on maternal health care

delivery, 37 National Policy Documents). The re-

cently completed MDG Report for 2010 provided

additional data and information on the MDGs

including the impact (existing/potential) of the

global economic crises and climate change on the

attainment of the MDGs. Focused group discus-

sions and rapid survey questionnaires to District

Directors of Health Service were also conducted.

• 

The National Technical Team with the consultants

and the UN inter-agency team, including a Re-

source Person from UNDP Regional Service Center,

Dakar, undertook a ﬁve-day working session in

Kumasi and reviewed the necessary interventions,

identiﬁed and prioritized bottlenecks as well as se-

quenced the solutions to remove the bottlenecks

for eﬀective implementation to accelerate MDG 5.

• TheTechnicalTeamfurtherreconvenedinAccra

to prepare the draft CAP including the Monitoring

& Evaluation framework. At that point, additional

resource persons from UNDP Regional Bureau for

Africa (RBA) and Bureau for Development Policy

(BDP) joined the team to share global experiences

in the MAF process and provided technical inputs for

quality assurance in line with the global programme.

• TheNationalTechnicalTeambriefedUNCTaday

prior to the validation meeting to share the ﬁnd-

ings, and received inputs for consideration mainly

in the areas of nutrition, gender empowerment,

girls’ education, HIV/AIDS and sexually transmitted

infections in pregnancy and childbirth.

• On12August2010,avalidationmeetingwas

organized with the wider stakeholders to discuss

and build consensus on the draft MAF CAP. The

validation provided further comments and recom-

mendations that further enhanced the quality and

ownership for the CAP. In all, 15 Agencies and 35

participants were represented.

• TheNationalTechnicalTeam,includingtheUN

Country Team, incorporated stakeholders’ com-

ments and contributions into the MAF CAP.

• Thedocumentwasdulyendorsedandnalizedas

a true reﬂection of Ghana’s MAF National Action

Plan for the acceleration of MDG 5 over the next

ﬁve years until the target date of 2015.

From the review of the existing policies and interven-

tions available for attaining MDG 5 in Ghana, the

team assessed the implementation status (whether

partially or not implemented) and the expected con-

tributions to the acceleration of MDG 5. It identiﬁed

and ranked the various interventions by using the

following set of criteria: impact, sustainability, speed,

coverage and available capacity for the intervention.

The three key interventions that emerged as having

great impact on maternal health were family plan-

ning (FP); skilled delivery services (SD); and emer-

gency obstetrics and neonatal care (EmONC).

Using the above three key intervention areas, the

team identiﬁed and prioritized the key bottlenecks

by answering questionnaires and ranking the bot-

tlenecks as high, medium or low/small, in the areas

of policy/planning, ﬁnancing, service delivery, service

utilization and cross-cutting on the interventions.

The bottlenecks that emerged from this ranking

included accessibility, availability, coverage, knowl-

edge, acceptance, poverty, quality and intersecto-

ral coordination. Using available costing, the team

developed cost-eﬀective solutions for the three in-

terventions to accelerate progress of MDG 5 using

‘accelerating solutions prioritization criteria’ based

on impact (magnitude, speed and sustainability)

and feasibility (governance, capacity and funding

availability).

The outputs from the overall MAF process included

(i) an analysis of the national-, regional- and

district-level constraints to implementing the

well-deﬁned actions required to make progress on

MDG 5, with emphasis on answering the question:

Why have the speciﬁc interventions not been im-

plemented; (ii) a two-to-three-year business plan/

CAP outlining how all stakeholders could work to-

gether to implement the various plans and initiatives.

The CAP elaborates on key prioritized interventions

that are required to achieve MDG 5, identiﬁes the

bottlenecks, and suggests cost-eﬀective solutions

to address the bottlenecks and accelerate progress.

It also contains an implementation and monitoring

plan for tracking progress. All these are with a view

to addressing the critical constraints that hamper

progress towards reducing maternal mortality in

Ghana and once again put the country on track to

achieving MDG 5 by 2015.

1.4.4: September 2010 MDG

Summit

In September 2010, 10 years after the historical event

of the MDG declaration in 2000, the global leaders

involved in formulating the declaration met again to

review the progress made, and galvanized political

commitment and collective action towards the 2015

deadline. In line with the country’s own concerns and

plans, Ghana was selected by the UN system along

with 10 countries (four in Africa — Ghana, Tanzania,

Togo and Uganda) to develop a CAP for the accelera-

tion of MDG 5. The results of the pilot, which was part

of a synthesis report, was tabled at the 2010 MDG

Summit in September 2010 in New York.

PROGRESS AND CHALLENGES

IN ACHIEVING MDG 5

Photo: Kayla Keenan

CHAPTER 2:

2.1: OVERVIEW OF MDG REPORT

2010 ON MDG 5  MATERNAL

MORTALITY IN GHANA

Although Ghana has achieved progress in the past

10 years of MDG implementation, challenges of in-

equalities, geographical disparities and sustaining

progress still remain. With only ﬁve years remaining

to the MDG deadline, Ghana will have to accelerate

its eﬀorts towards the achievement of all the MDGs,

especially those lagging behind such as MDG 4 (child

mortality), MDG 5 (maternal health) and part of MDG

7 (environment). The death of a mother, especially

during pregnancy, is a calamity for the family, com-

munity and society at large, something that has

been long accepted by all societies. Consequently,

it has been a concern of the international commu-

nity and various governments to initiate policies,

programmes and strategies to improve maternal

health and reduce maternal mortality and morbidity.

Unfortunately, the MMR is just too high in developing

countries, including Ghana, and the indicator is ac-

cepted as a key to assessing the level of development

of a particular country. While the MMR in developed

regions was 9 per 100,000 live births in 2008, the ratio

was 450 per 100,000 in developing regions (MDG

Report 2010). Obviously, a lot needs to be done in

developing regions to bring down the MMR if MDG

5 is to be achieved.

The MMR as captured by both survey and insti-

tutional data has shown an improvement over

the past 20 years. However, the pace has been

slow. Between 1990 and 2005, it reduced from

740 to 503 per 100,000 live births and then to 451

deaths per 100,000 live births in 2008. This trend

is also supported by institutional data which suggest

that maternal deaths per 100,000 live births have

declined from 224 per 100,000 in 2007 to 201 per

100,000 in 2008, after an increase from 187/100,000

in 2004 to 197 per 100,000 in 2006. If the current

trends continue, maternal mortality will be reduced

to only 340 per 100,000 by 2015 instead of the MDG

target of 185 per 100,000 by 2015. Moreover, the

improvements recorded are not evenly distributed.

There are disparities in the MMR (institutional) across

the 10 regions in Ghana from 1992 to 2008. The MMR

has decreased to 195.2 per 100,000 in the Central and

Upper East regions; 141 per 100,000 in the Northern

and Western Regions; 120.1 per 100,000 in Volta and

the Eastern Regions; and 59.7 per 100,000 in the

Upper West, Brong Ahafo and Ashanti regions. The

only region where the MMR has worsened is Greater

Accra (by 87.6 per 100,000) (ﬁg. 2). This shows a clear

inequity in the per capita distribution of health facili-

ties and health personnel across the various regions

and districts and underscores the need to improve it.

Unless extreme eﬀorts are made by all stakeholders,

Ghana is unlikely to meet the MDG target (ﬁg.1). The

Ghana Maternal Health Survey 2007 found that 14

percent of deaths of women within the reproductive

age are childbirth-related and identiﬁed hemorrhage

(24 percent) as the largest single cause of maternal

deaths; abortion was the second single largest cause

of death, accounting for 15 percent. Hypertensive

disorders, sepsis, and obstructed labour were also

cited as causes of maternal death.

The MMR remains unacceptably high in Ghana in

spite of the eﬀorts being made to reduce it. Maternal

health has remained a national priority and as such,

has become a core indicator for poverty reduction

in the Ghana Poverty Reduction Strategy (GPRS).

Additionally, improving maternal health and thereby

reducing maternal mortality is one of the priorities

of the health sector’s programme of work (POW).

Figure 1 TRENDS IN MATERNAL MORTALITY

Source: Ghana’s Health Sector Review Report, 2009; MOH, 2008.

740

503

451

150

250

350

450

550

650

750

1990 1995 2000 2005 2010 2015

Maternal Mortality Rate (per 100,00 live births)

Survey

Survey Path to Target Linear Trend

216

187

197

224

201

100

150

200

250

300

1990 1995 2000 2005 2010 2015

Maternal Mortality Rate (per 100,00 live births)

Instuonal

Instuonal Path to Target Linear Trend

Source:

Centre for Health Information Management

Ministry of Health

Northern (141.9)

Brong Ahafo (59.7)

Ashanti (42.7)

Volta (113.9)

Western (130.2)

Eastern (120.1)

Upper West (42.4)

Upper East (179.2)

Central (195.2)

Greater Accra (-87.6)

Baseline

Current Status

Portion of target met

Portion remaining

Maternal Mortality Ratio - Institutional

Change in affected population 1992 - 2008

Condition worsened by -87.6 per 100,000

Improved by up to 59.7 per 100,000

Improved by up to 120.1 per 100,000

Improved by up to 141. per 100,000

Improved by up to 195.2 per 100,000

Prepared for National Planning Commission (Ghana)

By African Centre for Statistics, UNECA

April 2010

Figure 2 MAP OF INSTITUTIONAL MATERNAL MORTALITY RATIO IN GHANA

BY REGION

While acknowledging the importance of focusing on

MDG 5, we also recognize that all the eight MDGs

are interrelated and mutually reinforcing. Poverty,

gender inequality, low productivity, inadequate

income opportunities, poor education, environ-

mental non-sustainability are all undermined

if health care is poor and the reverse is true in

some cases. For instance, MDGs 4, 5 and 6 are close-

ly linked. The mother is the fulcrum around which

family life revolves and her death jeopardizes the

survival of her young children. For example, the risk

of death for children under ﬁve is higher for those

whose mothers die in childbirth than those with

living mothers. Reducing death in pregnancy and

childbirth does not only improve the productivity

of women, and increase labour supply and the eco-

nomic well-being of communities, but is arguably

also a human r

ights issue. Given the numerous is-

sues that beset maternal health care leading to slow

progress in achieving MDG 5, and the inter-linkages

between improved maternal health and MDG 4, the

MAF roll-out in Ghana chose to focus on MDG 5. The

status of the MDGs in Ghana over the last 10 years

is shown in table 3.

2.2: OVERALL ASSESSMENT OF

PROGRESS TOWARDS MDG 5

Policy measures for improving health care services

in general, and maternal care in particular, are en-

shrined in the national development policy frame-

works including the GPRS I, GPRS II and the draft

Medium-Term National Development Policy Frame-

work 2010–2013 as well as speciﬁc health sector poli-

cies. Furthermore, Ghana has numerous initiatives in

place to address the issue of maternal mortality but

the results have not led to desirable improvement

in MDG 5. Particular initiatives put in place to ad-

dress the high levels of maternal deaths include the

Safe-Motherhood Initiative, Ghana Vitamin A Supple-

ment Trials (VAST) Survival Programme, Prevention

of Maternal Mortality Programme (PMMP), Making

Pregnancy Safer Initiative, Prevention and Manage-

ment of Safe Abortion Programme, Intermittent

Preventive Treatment (IPT), Maternal and Neonatal

Health Programme and the Roll Back Malaria Pro-

gramme. However, funding and other cross-cutting

constraints have hampered the full implementation

of some of the initiatives.

Resource allocation to the health sector in nominal

terms has increased over the years. However, as a

percentage of the national budget it declined from

16 percent in 2006 to about 12.76 percent in 2009.

TABLE 1 HEALTH BUDGET 20062009

Year 2006 2007 2008 2009

MoH 478,654,800 563,756,400 752,233,368 921,929,472

National budget 2,948,398,300 3,869,832,200 5,059,808,063 7,226,913,484

Total share of health in the

national budget 16.23% 14.60% 14.90% 12.76%

Source: Annual Budget Statement, MoH, Government of Ghana.

Apart from the general bottlenecks that aﬀect the

entire health system of the country, there are also

speciﬁc urban and rural challenges with implica-

tions for maternal mortality. Antenatal care from

health professionals (nurses, doctors, midwives

or community health oﬃcers) increased from 82

percent in 1988 to 95 percent in 2008 (see ﬁgure

3). However, the progress is unevenly distributed.

While women in urban areas receive more antenatal

care from health professionals (98 percent) than

their rural counterparts (94 percent) the regional

ﬁgures are diﬀerent: 96 percent to 98 percent of

women across all the regions received antenatal

care from health professionals. The exception is

women in Volta and the Central regions whose

antenatal care access rate is estimated at 91 percent

and 92 percent respectively. However, the lack of

information available to women about signs of

complications in pregnancy, and access to basic

laboratory services, particularly in the Northern and

Upper West regions, aﬀect the quality of antenatal

care. In the Northern and Upper West regions, only

six in 10 pregnant women, and two in three have

access to urine testing and blood testing respec-

tively. These are against the national average of 90

percent access to these services.

Figure 3 SELECTED INDICATORS OF REPRODUCTIVE HEALTH CARE,

19882008

Source: Ghana Statistical Service (2005, 2008), Ministry of Health (2006).

Deliveries that were assisted by a health profes-

sional recorded slow progress, increasing from

40 percent in 1988 to 59 percent in 2008. In the

Northern region, one in four compared to four in

five children in the Greater Accra region are likely

to be delivered in a health facility. Professional

assistance at birth for women in urban areas was

found to be twice as likely to occur as in rural

areas (MOH, 2008a). The available data show that

over 40 percent of women did not deliver in a

health facility because some of them thought

it was unnecessary to do so, while others cited

lack of money, accessibility problems like distance

to a health facility, transportation problems, not

knowing where to go, and the unavailability of

someone to accompany them to the facility. The

Reproductive and Child Health Policy recom-

mends a minimum of four visits per client and a

haemoglobin check at registration and at term.

The four-plus visit coverage has stayed below

60 percent against the target of 80 percent and

the proportion of women whose haemoglobin is

checked at term remains below 10 percent.

While puerperal sepsis is a significant cause of

maternal deaths, postnatal care coverage has per-

sistently remained low and stagnated between 53

percent and 56 percent from 2001 to 2007 (fig. 4).

Figure 4 POSTNATAL CARE COVERAGE

FP prevents unwanted pregnancy and reduces the

risk of maternal deaths from pregnancy-related com-

plications and unsafe abortions. But the FP acceptor

rate has seen only a marginal rise from 21.2 to 25.4

percent of women in their reproductive age between

2007 and 2009. Greater Accra and the Western and

Ashanti regions have particularly low acceptor rates.

The Upper West and Brong Ahafo regions record

the highest FP acceptor rates (ﬁg. 5). The preferred

methods are Depo (44.3 percent), male condom

(27.7 percent), combined pills (15.9 percent) and

injectable Norigynon.

54.2

53.4

55.7

53.3

53.7

56.7

2001 2002 2003 2004 2005 2006 2007

Postnatal Care Coverage(%)

Figure 5 FAMILY PLANNING ACCEPTOR RATE BY REGION, 20072009

AS BA CR ER GAR NR UE UW VR WR NAT

2007

2008

2009

Figure 6 DEMAND FOR FAMILY PLANNING AMONG CURRENTLY MARRIED

WOMEN

Ghana has a National Contraceptive Security (CS)

Strategic plan, supported by a Financial Sustain-

ability Plan (FSP). In 2007, however, there was a “near

crisis” in the supply of male condoms as the country

almost ran out of stock of Neo Sampoon spermicide,

which is the most preferred type. The demand for

FP among currently married women is 59 percent,

out of which only 24 percent have their demand

satisﬁed and 35 percent have an unmet need (ﬁg.

6). The main challenges in FP include contraceptive

security issues (funding gap in procurement, and in

information, education and communication) and

method-speciﬁc issues (low patronage of contracep-

tive devices such as intrauterine devices (IUDs) and

female condoms due to low male involvement and

fear of side eﬀects). The current funding requirement

(2010–2012) prior to the MAF process is estimated

at $41.2 million as shown in table 2.

TABLE 2 TOTAL CONTRACEPTIVE FUNDING REQUIREMENTS BY PROGRAMME, 20102012

IN MILLIONS USD

Product 2010 2011 2012 Total

MoH (PPAG/MBI) 11.6 8.4 13.5 33.5

EXP SM 2.9 2.4 2.4 7.7

TOTAL 14.5 10.8 10 41.2

The Community Health Planning and Service (CHPS)

was initiated in Ghana in 2000 to bridge the equity

gap in health services by partnering health pro-

vider and community eﬀorts, to bring health services

closer to the doorstep of households. It involves

subdividing sub-districts (15,000–30,000 population)

into zones with a population of 2,000 to 5,000, as-

signing trained health workers, providing them with

logistics and with support from community health

volunteers, delivering preventive and curative care

and in some cases midwife services. Currently, it is

estimated that 2,200 CHPS zones are functional in

Ghana (ﬁg. 7). While the concept is good, it is chal-

lenged by inconsistent targeting (both in numbers

and in relation to the Ghana poverty map), lack of

human resources and very often a diﬀerent interpre-

tation of what constitutes a functional CHPS zone.

Behavioural change communication (BCC) is another

key initiative to create awareness about pregnancy

risk factors and danger signs, and increase demand

and utilization of antenatal services, SD services,

EmONC and postnatal care. The programme uses

the media to inform, educate and communicate

messages to promote the adoption of desired be-

haviours; prints posters, leaﬂets and ﬂiers; engages in

advocacy; involves traditional leaders and religious

leaders and groups, and so on. Recently, with support

from UNICEF, the Health Promotion Department of

the Ghana Health Service (GHS) developed a com-

mon framework for behavioural change termed

‘Communication for Development’ (C4D).

The high maternal mortality in the country was de-

clared a national emergency in 2008 and therefore

emphasized the need to assign a higher priority to

reproductive health services. Unfortunately, resource

allocation was not aligned to match this good pol-

icy declaration. Furthermore, there is no systematic

tracking of set targets such as focused antenatal

care coverage, the percentage of facilities oﬀering

basic emergency obstetric care (BEOC), the percent-

age of districts oﬀering comprehensive emergency

obstetric care (CEOC), and the percentage of districts

with transfusion service. Issues of accessibility often

emerge as a bottleneck for pregnant women, par-

ticularly in rural areas. Sometimes, pregnant women

are not able to aﬀord transport or do not know where

to access maternal health services.

Figure 7 VARIATIONS IN CHPS DEPLOYMENT TARGETING

0 0 0 0

-58

-38

-62

-22

-56

-16

-19

-14

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 )2015

CHPS Deployment Diﬀerences in Target

Yearly diﬀerence

TABLE 3 STATUS OF MDGS AND TRENDS TOWARDS ACHIEVING THEM

Goals/Targets Indicator Indicator Status MDG Target

1999 2001 2002 2003 2004 2005 2006 2007 2008 2015

Goal 1. Eradicate Extreme

Poverty and Hunger

a. Halve the proportion of

people below the extreme

poverty line by 2015

b. Halve the proportion of

people who suer from hunger

Proportion below

extreme poverty

(national basic needs) line (%)

Proportion below

upper poverty line (%)

Proportion of children

malnourished (%)

-Underweight

- Stunting

- Wasting

26.8

39.5

23 (1988)

(1988)

(1993)

20 (1998)

(1998)

10.0

(1998)

18.0

28.5

13.9

18.5

25.8

15.5

3.8

Goal 2: Achieve Universal

Primary Education

Achieve universal access to

primary education by 2015

- Gross enrolment ratio (%)

- Net primary

enrolment ratio (%)

- Primary completion/

survival rate (%)

72.7 (1990)

54 (1990)

63 (1990)

79.5 (2000)

61 (2000)

63 (2000)

83.2

85.7

59.1

82.6

92.1

69.2

75.6

93.7

81.1

85.4

95.2

83.7

88.0

100

Goal 3: Promote Gender

Equality and Empower Women

a. Eliminate gender disparity in

primary and junior secondary

education by 2009

b. Achieve equal access

for boys and girls to senior

secondary by 2009

Ratio of females to males in

primary schools (%)

Ratio of females to males in

junior secondary schools (%)

Ratio of females to males in

senior secondary schools (%)

Percentage of female

enrolment in senior secondary

schools (%)

0.92

0.88

0.77

0.88

0.93

0.88

0.95

0.88

43.5

0.95

0.88

49.5

0.96

0.91

0.96

0.92

1.0

TABLE 3 STATUS OF MDGS AND TRENDS TOWARDS ACHIEVING THEM

Goals/Targets Indicator Indicator Status MDG Target

1999 2001 2002 2003 2004 2005 2006 2007 2008 2015

Goal 1. Eradicate Extreme

Poverty and Hunger

a. Halve the proportion of

people below the extreme

poverty line by 2015

b. Halve the proportion of

people who suer from hunger

Proportion below

extreme poverty

(national basic needs) line (%)

Proportion below

upper poverty line (%)

Proportion of children

malnourished (%)

-Underweight

- Stunting

- Wasting

26.8

39.5

23 (1988)

(1988)

(1993)

20 (1998)

(1998)

10.0

(1998)

18.0

28.5

13.9

18.5

25.8

15.5

3.8

Goal 2: Achieve Universal

Primary Education

Achieve universal access to

primary education by 2015

- Gross enrolment ratio (%)

- Net primary

enrolment ratio (%)

- Primary completion/

survival rate (%)

72.7 (1990)

54 (1990)

63 (1990)

79.5 (2000)

61 (2000)

63 (2000)

83.2

85.7

59.1

82.6

92.1

69.2

75.6

93.7

81.1

85.4

95.2

83.7

88.0

100

Goal 3: Promote Gender

Equality and Empower Women

a. Eliminate gender disparity in

primary and junior secondary

education by 2009

b. Achieve equal access

for boys and girls to senior

secondary by 2009

Ratio of females to males in

primary schools (%)

Ratio of females to males in

junior secondary schools (%)

Ratio of females to males in

senior secondary schools (%)

Percentage of female

enrolment in senior secondary

schools (%)

0.92

0.88

0.77

0.88

0.93

0.88

0.95

0.88

43.5

0.95

0.88

49.5

0.96

0.91

0.96

0.92

1.0

Goals/Targets Indicator Indicator Status MDG Target

1999 2001 2002 2003 2004 2005 2006 2007 2008 2015

Goal 4: Reduce Child Mortality

Reduce under-ve mortality by

two-thirds by 2015

- Under-ve mortality rate

(per 1,000 live births)

- Immunization coverage (%)

122

(1990)

110

(1995)

(2000)

109

(2000)

111

39.88

100

Goal 5. Improve Maternal

Health

Reduce maternal mortality

ratio by three quarters by 2015

- Maternal mortality per

100, 000 live births (survey)

- Maternal mortality

per 100, 000 live births in

health facilities (institutional)

- Births attended by skilled

health personnel (%)

740

(1990)

216

(1990)

(1988)

260

(1993)

204

(1998)

205

187

503

205

197

224

451

201

185

100

Goal 6. Combat HIV/AIDS &

Malaria, and Other Diseases

a. Halt and reverse the spread

of HIV/AIDS by 2015

b. Halt and reverse the

incidence of malaria

National HIV prevalence

Rate (%)

Under-ve malaria case

fatality (Institutional) (%)

1.5

2.9

3.4

2.9

3.6

2.8

3.1

2.7

2.4

3.2

2.1

2.6

2.2

≤1,5

Goals/Targets Indicator Indicator Status MDG Target

1999 2001 2002 2003 2004 2005 2006 2007 2008 2015

Goal 4: Reduce Child Mortality

Reduce under-ve mortality by

two-thirds by 2015

- Under-ve mortality rate

(per 1,000 live births)

- Immunization coverage (%)

122

(1990)

110

(1995)

(2000)

109

(2000)

111

39.88

100

Goal 5. Improve Maternal

Health

Reduce maternal mortality

ratio by three quarters by 2015

- Maternal mortality per

100, 000 live births (survey)

- Maternal mortality

per 100, 000 live births in

health facilities (institutional)

- Births attended by skilled

health personnel (%)

740

(1990)

216

(1990)

(1988)

260

(1993)

204

(1998)

205

187

503

205

197

224

451

201

185

100

Goal 6. Combat HIV/AIDS &

Malaria, and Other Diseases

a. Halt and reverse the spread

of HIV/AIDS by 2015

b. Halt and reverse the

incidence of malaria

National HIV prevalence

Rate (%)

Under-ve malaria case

fatality (Institutional) (%)

1.5

2.9

3.4

2.9

3.6

2.8

3.1

2.7

2.4

3.2

2.1

2.6

2.2

≤1,5

Goals/Targets Indicator Indicator Status MDG Target

1999 2001 2002 2003 2004 2005 2006 2007 2008 2015

Goal 7:

Ensure Environmental

Sustainability

a. Integrate the principles

of sustainable development

into country policies and

programmes and reverse the

loss of environmental resources

b. Halve the proportion of

people without access to safe

drinking water

by 2015

a. Proportion of

land area covered by

forest (ha/annum)

b. Annual rate of

deforestation (%)

Proportion of population with

access to safe drinking water (%)

-Urban

-Rural

Proportion of population with

access to improved sanitation (%)

-Urban

-Rural

Population with access to

secure housing (%)

Population living in slums (%)

6,229,400

(27.4 % of

total land

area)

1.82

(135,400 ha)

(1990)

27.2 (1990)

1.89

(115,400 ha)

(1993)

25.5

(1998)

5,517,000

(24.3% of

land area)

1.7

(93,789 ha)

11.4

20.7

83.8

76.6

12.4

17.8

8.2

12.5

19.6

≥7,448,000 ha

≤1.82%

69.5

50.5

18.5 (2020)

<13

Goals/Targets Indicator Indicator Status MDG Target

1999 2001 2002 2003 2004 2005 2006 2007 2008 2015

Goal 7:

Ensure Environmental

Sustainability

a. Integrate the principles

of sustainable development

into country policies and

programmes and reverse the

loss of environmental resources

b. Halve the proportion of

people without access to safe

drinking water

by 2015

a. Proportion of

land area covered by

forest (ha/annum)

b. Annual rate of

deforestation (%)

Proportion of population with

access to safe drinking water (%)

-Urban

-Rural

Proportion of population with

access to improved sanitation (%)

-Urban

-Rural

Population with access to

secure housing (%)

Population living in slums (%)

6,229,400

(27.4 % of

total land

area)

1.82

(135,400 ha)

(1990)

27.2 (1990)

1.89

(115,400 ha)

(1993)

25.5

(1998)

5,517,000

(24.3% of

land area)

1.7

(93,789 ha)

11.4

20.7

83.8

76.6

12.4

17.8

8.2

12.5

19.6

≥7,448,000 ha

≤1.82%

69.5

50.5

18.5 (2020)

<13

Goals/Targets Indicator Indicator Status MDG Target

1999 2001 2002 2003 2004 2005 2006 2007 2008 2015

Goal 8: Develop a Global

Partnership for Development

Deal comprehensively

with debt and make debt

sustainable in the long term

Public debt ratio (% of GDP)

External

Domestic

Total

External debt service as a

percentage of exports of

goods & services

ODA Inows (% of GDP)

Total

Programme Aid

152.8

(2000)

28.9

(2000)

181.65

(2000)

7.8

(1990)

114.8

26.8

141.61

10.1

105.4

28.5

133.85

10.2

100.7

20.5

121.26

5.2

21.2

94.18

5.6

59.6

18.8

78.35

5.8

24.4

41.42

3.2

8.1

37.6

24.6

26.2

50.87

8.1

27.7

27.5

55.2

4.3

8.6

Source: Ghana MDG Report 2010.

* As reported in MoH-MNCH Strategy (2009–2015).

** MoH has changed the target from 80 percent to 55 percent in the MNCH Strategy (2009-2015).

***Ministry of Agriculture and Forestry, Forestry Sector Strategy.

Goals/Targets Indicator Indicator Status MDG Target

1999 2001 2002 2003 2004 2005 2006 2007 2008 2015

Goal 8: Develop a Global

Partnership for Development

Deal comprehensively

with debt and make debt

sustainable in the long term

Public debt ratio (% of GDP)

External

Domestic

Total

External debt service as a

percentage of exports of

goods & services

ODA Inows (% of GDP)

Total

Programme Aid

152.8

(2000)

28.9

(2000)

181.65

(2000)

7.8

(1990)

114.8

26.8

141.61

10.1

105.4

28.5

133.85

10.2

100.7

20.5

121.26

5.2

21.2

94.18

5.6

59.6

18.8

78.35

5.8

24.4

41.42

3.2

8.1

37.6

24.6

26.2

50.87

8.1

27.7

27.5

55.2

4.3

8.6

STRATEGIC

INTERVENTIONS

Photo: Kayla Keenan

CHAPTER 3:

3.1: STRATEGIC INTERVENTIONS

OF HIGH IMPACT FOR THE

ACHIEVEMENT OF MDGS

Most of the interventions that have been pursued

to curb the high incidence of maternal mortality

over the years are similar to those for under-ﬁve

mortality. They include:

(i) establishment of at least one fully operational and

furnished hospital in every district to deal with

complications from maternal health delivery;

(ii) result-oriented strategies for under-ﬁve children,

maternal health care and malnutrition;

(iii) increased access to health services under the

NHIS;

(iv) high vaccination coverage, increased use of

insecticide-treated nets;

(v) continuous advocacy to district assemblies (DAs)

and DHMTs to devote more resources to mater-

nal and child health;

(vi) expansion of community-based health service

delivery.

Additional policies, strategies and interventions

being pursued over the years to address the MMR

include the following:

• reproductivehealthstrategy;

• RoadMapforAcceleratingtheAttainmentofthe

MDGs related to Maternal and Newborn Health

in Ghana;

• StandardsandProtocolsforPreventionandMan-

agement of Unsafe Abortion: Comprehensive

Abortion Care Services;

• WheelforImprovingAccesstoQualityCareinFP:

Medical Eligibility Criteria (MEC) for Contraceptive

Use;

• RoadMapforRepositioningFP;

• declaringmaternalmortalityanationalemer-

gency in 2008 and a programme of free health

care for pregnant women including deliveries

through the NHIS;

• strengtheningofCommunityHealthPlanning

Services (CHPS) to facilitate the provision of mater-

nal health services; and expansion of community-

based health service delivery;

• toincreasesuperviseddeliveryatthedistrictlevel,

targeting of pregnant women for NHIS registration,

raising community awareness through CHPS zones,

Community Health Oﬃcers outreach education and

mobilization of community leaders, etc.;

• continuouseducationtotraditionalmaternal

health service providers to ensure preventable

maternal deaths;

• ongoingprocesstomakematernaldeathanoti-

able event backed by legislation;

• reductionofguineawormcases,andimprove-

ment of tuberculosis treatment;

• introductionofstepstoreviseguidelinesforthe

conduct of maternal death audits and to establish a

system of conﬁdential enquiry into maternal deaths.

Analyses of these policy and strategic documents

and consultations with health managers have shown

the multi-dimensional initiatives adopted by Ghana

to address issues of maternal health. Further initia-

tives in addition to the ones above include free Am-

bulance Services for Obstetric Emergency, Focus ANC

and Supervised Delivery, Prevention of Mother to

Child Transmission/Counselling and Testing PMTCT/

CT for all pregnant women, free maternal care/deliv-

ery, comprehensive abortion care, adolescent health

programmes, providing communications, logistics

and equipment for referral systems, and supervision

and monitoring of maternal services. Additional ini-

tiatives include the use of insecticide-treated nets,

High Impact Rapid Delivery (HIRD) interventions,

CHPS, expansion of blood transfusion services and

promotion of good nutrition. In spite of these eﬀorts

maternal deaths still remain high at 503 per 100,000

live births in 2005 and 451 per 100,000 live births in

2007. If nothing is done to accelerate progress and

the current trends continue, maternal mortality will

be reduced to only 340 per 100,000 instead of the

MDG target of 185 per 100,000 by 2015.

Under a Ministerial Task Team/Technical Team, the

Government of Ghana has identiﬁed three key priority

interventions, among several ongoing ones, with the

objective of achieving maximum beneﬁt and ensuring

better coordinated eﬀort and impact (table 5). These are:

1. Family planning

2. Emergency obstetric and neonatal care

3. Skilled attendant at delivery

3.1.1: Family planning

Eﬀective FP is one of the high-impact interven-

tions that reduce the risk of maternal deaths from

pregnancy-related complications and unsafe abor-

tions. But as indicated in the earlier chapter, the FP

acceptor rate remained low, at 21.2 to 25.4 percent of

women in their reproductive age, between 2001 and

2007. There are major regional variations in coverage.

The interventions are intended to reposition FP to

improve awareness methods especially at a time

when Ghana has already revised its Contraceptives

Procurement Tables and introduced an MEC wheel

to improve procurement and quality, respectively.

The intervention will seek to improve FP coverage

with speciﬁc focus on:

• improvingsupplyanddistributionofFPcom-

modities;

• improvingcapacityinprovisionofFPservices;

• improvingpublicawarenessandunderstandingof

maternal health in diﬀerent areas including FP, SD,

EmONC, nutrition, sexually transmitted infections

(STI), HIV/AIDS, gender issues, etc.

3.1.2: Skilled delivery coverage

The analysis also showed that SD is key to good ma-

ternal health care. Labour and delivery is the shortest

and most critical period–childbirth continuum. Most

maternal deaths occur from complications during

delivery. Even with the best possible antenatal care,

any delivery can become complicated. Therefore,

skilled assistance is required for a safe delivery.

There have been several attempts to widen coverage

of SD services and improve service utilization. These

include posting announcements of the introduc-

tion of free delivery, NHIS, community education

to improve demand, appointment of midwives to

health centres and CHPS compounds, and oﬀering

training in life-saving skills. A mix of strategies exists

to improve the quality of SD care, including monitor-

ing the use of partographs, audits of maternal deaths

and maternal death notiﬁcation.

However, the SD rate has remained low, at 59 percent

(GDHS 2008) annually, compared to the antenatal

registrant rate of above 90 percent. The challenges

explaining the low rate of SD, among others, are the

provider’s attitude, sociocultural challenges and in-

adequate number of midwives. Table 4 below shows

the various categories and number of health staﬀ in

2007 and the number required in 2010.

SD is central to achieving the MDG 5 target of a

reduction in maternal mortality by three quarters.

The interventions will seek to improve SD coverage,

and the prioritized actions will involve:

• improvingmonitoringofallstagesoflabour(e.g.,

use of partographs) and the care of the newborn

in the postnatal period;

• maintainingtheimplementationoftheFreeMa-

ternal Delivery policy in line with the NHIS;

• rollingoutCHPS,andstrengtheningreferraland

community support systems to address obstetric

emergencies;

• Extendingthereachofanintegratedpackageof

services through the HIRD approach.

3.1.3: Emergency Obstetric and

Neonatal Care

Pregnant women die from obstetric complications

that most times are not predictable. Improving ac-

cess to basic and comprehensive essential obstetric

care provides women with such complications the

care they need to survive. The Ghana government

through the MoH provides equipment, logistics and

medicines for Comprehensive Emergency Obstetric

Care (CEOC)and Comprehensive Essential Newborn

Care (CENC), monitors availability of BEOC and Es-

sential Neonatal Care (ENC) and expanded blood

transfusion services to meet maternal health needs.

For a facility to provide SD and provide essential care,

there is need for a midwife and/or a doctor with the

requisite training and orientation. In the last few

years, Ghana has established more midwifery schools

TABLE 4 HUMAN RESOURCE REQUIREMENTS 2010 AND STATUS AS OF 2007, GHANA

Category of sta

Total number

2007

Number required

by 2010

Medical ocers 2,026 3,732

Dental surgeons 31 50

Pharmacists 1,550 2,726

Expatriate doctors 200 -

Professional nurses 7,304 19,000

Enrolled nurses 2,956 -

Community health nurses 3,246 12,934

Registered midwives 2,810 8,205

Medical assistants 430 1,242

Allied health professionals 588 2,500

Traditional birth attendants 367 -

Non clinical & clinical support sta 27,918 31,100

Health assistants (clinical) - 7,176

(Direct Midwifery Diploma programme 2003) and

increased intake into existing schools. Despite this,

the country continues to have inequities in access

to health services resulting in large disparities in

reproductive and maternal health indicators. The

Ashanti region is the largest contributor to maternal

deaths. Yet, the region disproportionately continued

to receive ﬁnancial support compared to inﬂows to

each of the other four ‘deprived’ regions.

Ghana also experiences gaps in monitoring and

tracking of EmONC, as well as gaps in selected es-

sential outputs and outcomes as a percentage of

facilities oﬀering BEOC, the percentage of districts

oﬀering CEOC and the percentage of districts with-

out transfusion services. As in the case of SD care,

the availability of human resources and adequate

distribution also remain a challenge. In 2007, Ghana

prepared a road map for accelerating the attainment

of MDG 5-related maternal and neonatal health in

Ghana. It focused on HIRD as a framework to use

evidence-based feasible and cost-eﬀective inter-

ventions in resource-poor settings to achieve an

accelerated reduction in maternal and newborn

deaths, through increased ANC and PNC coverage,

more SD, better access to CEOC, and the promotion

of sound individual, family and community practices.

The three key areas prioritized for improving BEOC

and neonatal care includes:

• scalinguptheprocurementandimprovingdis-

tribution of BEmONC and CEmONC equipment

to health centres and hospitals, respectively;

• improvingreferralandstrengthenBloodTransfu-

sion Services (BTS) in line with the National Blood

Transfusion Policy;

• scalingupLifeSavingSkills(LSS)trainingand

building Regional Resource Teams.

Figure 8.2

TABLE 5 SUMMARY MATRIX OF KEY PRIORITY INTERVENTIONS AND INDICATIVE INTERVENTIONS, GHANA

MDG MDG indicator # Key interventions # Prioritized interventions

(adapted to the country context)

2011–2015

Goal 5:

Improve

Maternal

Health

Target 5a:

Reduce

MMR by

three fourths

between 1990

and 2015

to 185 per

100,000 live

births

5.1 MMR

5.2 Proportion of births

attended by skilled health

personnel (SD rate)

1 Improving FP

coverage

1 Improving FP commodities supply

and distribution

2 Improving capacity in FP service

provision

3 Improving public awareness

and understanding of maternal

health including FP, SD, EmONC,

Nutrition, STI, HIV/AIDS, gender

issues, etc.

2 Improving SD

coverage

1 Improve monitoring of all stages

of labour (e.g., use of partograph),

of the care of the newborn and

the postnatal period

2 Maintain the implementation of

the Free Maternal Delivery policy

in line with the NHIS

3 Roll out CHPS, strengthen referral

and community support systems

to address obstetric emergencies

4 Extend the reach of integrated

package of service provision

through HIRD approach

3 Improving access to

EmONC

1 Scale up the procurement and

improve distribution of BEmONC

and CEmONC equipment to

health centres and hospitals

respectively

2 Improve referral and strengthen

BTS in line with the National

Blood Transfusion Policy

3 Scale up LSS training and build

Regional Resource Teams

4) The integrated package of services through HIRD includes some of elements of FP, SD and EmONC.

BOTTLENECK

ANALYSIS

Photo: Kayla Keenan

CHAPTER 4:

4.1: BOTTLENECKS

In the execution of interventions to reduce maternal

mortality, Ghana is challenged with many bottle-

necks related to FP, SD and BEOC that have been

identiﬁed during the implementation of initiatives

and strategies or in their documentation that was

shared among implementers and mangers. These

bottlenecks relate to access, utilization, quality, com-

modity provision, governance, funding and part-

nership. These have been analysed to ensure that

solutions match priority bottlenecks to maximize

impact. Evidence shows that if these bottlenecks

are removed, it can signiﬁcantly improve maternal

health.

The prioritization of bottlenecks was based on poli-

cy/planning, budget and ﬁnancing, service delivery,

service utilization and cross-cutting initiatives, as

well as the time taken for the solution to address

the bottleneck (table 6). The bottlenecks in the three

priority areas are discussed below.

4.1.1: Family planning

Since the implementation of the ‘repositioning of

FP’ to improve comprehensive FP coverage, the fol-

lowing bottlenecks, among many others, that slow

down the achievement of set targets still persist:

• stockutilizationandinventorymanagementis-

sues (including incomplete data, late reporting

and the irregular physical count of commodities);

• poorcounselling(forexample,onhowtouse

the MEC wheel) and low provider capacity for

long-term contraception methods (IUDs, implant

insertions);

• inadequatesupervisionandmonitoringofservice

delivery;

• weakownershipofandsupportformaternal

health interventions by DAs;

• culturalissues(lowmaleinvolvementincluding

lack of male service points, perception of the up-

take of FP, and non-receptive maternity units/FP

clinics);

• fearofsideeectsamongwomen(irregularmen-

struation, amenorrhea, etc.).

4.1.2: Skilled delivery

The reach of SD has consistently remained below 60

percent in Ghana. It has been a major cause of worry

to the sector and many strategies are being adopted

to address the situation. Important measures put in

place include expansion of midwifery school intake,

the redistribution of midwives, LSS training, CHPS

and free childbirth delivery. The major bottlenecks

that remain include:

• improperapplicationofaninstitutionalgrading

system and lack of customized staﬃng ;

• weaksupervision,monitoringandlackofasystem

to measure staﬀ performance;

• inadequatenumberofmidwives,doctors,obstetri-

cians, and health tutors production;

• pooraccesstohealthfacilities,--geographically,

ﬁnancially, and culturally (e. g., CHPS, poor refer-

ral health system, i.e. (penetration and coverage

of the National Ambulance service), community

systems);

• inadequatefundingforlogisticsandinfrastructure;

• Pooralignmentofdonorsupporttogovernment

programmes.

4.1.3: Emergency Obstetric and

Neonatal Care

Universal access to BEOC and neonatal care guar-

antees the best chances of survival of women who

develop obstetric complications. Ongoing inter-

ventions towards this include providing theatres

and equipping health institutions, improving refer-

ral through expansion of the National Ambulance

Service, ensuring availability of doctors or obstetri-

cians, providing safe BTS and improving customer

care. Despite these, access to BEmONC and CEmONC

is poor. The main bottlenecks underlining the poor

access to EmONC are:

• inadequatefundingforcapital-intensiveinvest-

ments in infrastructure and equipment (e.g., CHPS

compounds, EmONC equipment);

• inadequateaccessibilitytocareservicesasaresult

of inadequate transport, poor road networks, weak

referral systems;

• inadequate production and procurement of

skilled health workers (midwives, doctors, obste-

tricians, gynaecologists, tutors);

• non-implementationofrecommendationsfrom

previous EmONC assessments;

• lackofapolicyframework;

• inadequatehumanresourcescapacityandequip-

ment to expand coverage of LSS and ENC services.

Some bottlenecks are cross-cutting across the three

priority interventions, and therefore, their removal

has overarching impact on maternal health in the

country. These are the following:

• Funding: The enormity of the challenges faced

seems to be bigger than what the available re-

sources can accomplish. Thus, the inadequate

mobilization of resources to address maternal

health interventions is a major stumbling block.

• Capacity: This covers both individual and insti-

tutional capacities. There is a dearth of qualiﬁed

health professionals and related workers to deliver

an eﬀective maternal health system care in the

country. For instance, the population per mid-

wife ranges between 5,357 (Upper West Region)

and 14,646 (Northern Region), while women of

reproductive age per midwife ranges between

920 (Volta) and 2161 (Ashanti). Incidentally, as

in 2007, the Ashanti region remained the largest

contributor (accounting for 20 percent of maternal

deaths in Ghana). Institutional capacity is also an

important issue in Ghana in terms of processes,

practices and institutional coordination, often

translating into weak absorptive capacity.

• Partnership coordination: There has been lim-

ited involvement of DAs, CSOs and non-govern-

mental organizations (NGOs) as well as the private

sector in the implementation of maternal health

in the country. Although the programme of de-

velopment partners in the health sector is aligned

with national health priorities, the challenge is

limited alignment in terms of sequencing, scope,

and pooling of resources together to achieve a

common target.

• Governance: A number of governance issues ex-

ist, relating to limited responsiveness to emerging

issues, weak transparency and accountability, lack

of eﬀective leadership, and decentralization. Most

maternal health activities are implemented at the

district and subdistrict levels, and usually there is

a signiﬁcant mismatch between the work to be

done and the resources allocated.

• Data generation and management: Eﬀective

monitoring of progress on maternal health re-

quires substantial data. However, data generation

and management constitute a major challenge to

progress monitoring in the country. Information

on monitoring and evaluation is equally limited.

• Cultural values: Cultural factors are frequently

mentioned in most national documents includ-

ing the Roadmap for Accelerating the Attainment

of the MDGs Related to Maternal and Newborn

Health in Ghana 2007 and Ghana Democratic and

Health Survey 2008. Sociocultural factors cause

women not to use some health care services,

especially when they are related to sexual and

reproductive issues.

If women’s lives can be saved, and maternal mortal-

ity reduced, every eﬀort should be made to address

these bottlenecks by applying the accelerating solu-

tions proposed in Chapter V and the commitment of

the Government of Ghana must be absolute.

TABLE 6: SUMMARY TABLE OF BOTTLENECKS TO KEY PRIORITY INTERVENTIONS TO ACHIEVE MDG 5

TARGETS, GHANA

Priority

interventions

Area(s)

Prioritized bottlenecks Bottleneck

category

(2) Improve

SD coverage

Improper application of institutional grading system and

lack of customized stang norm

Policy/planning and service delivery

Poor leadership and management practices, weak

supervision, monitoring and weak performance

measurement system s

Service delivery/cross-cutting across

priority interventions

Inadequate number of midwives, doctors, OBG specialists,

anaesthetists and midwifery tutors

Service delivery/ cross-cutting across

priority interventions

(Inadequate funding for operations, logistics and

infrastructure (Inadequate, late release, etc)

Financing/budget

Poor alignment of donor support with government

programmes, MoH policies and agencies, and resource

allocation

Policy-planning/ nancing-budget

Cross cutting

(3) Improve

access to

emergency

obstetric and

neonatal care

Inadequate funding for capital-intensive investments in

infrastructure and equipment (e.g., CHPS compounds,

EmONC equipment, PPM) and operational funds for service

delivery

Financing/budget

Inadequate accessibility as a result of inadequate transport,

poor road networks, weak referral system (i.e., penetration

and coverage of national ambulance service)

Service utilization

Inadequate production and procurement of skilled

health workers (midwives and doctors, obstetricians

and gynaecologists, and tutors (including for SD, IST,

anaesthesia etc.)

Service delivery

Non-implementation of recommendations of previous

EmONC assessment

Policy/planning

Lack of legal framework for BTS Policy/planning

Inadequate human resource capacity and equipment to

expand coverage of LSS and ENC services

Service delivery/ cross-cutting

ACCELERATING MDG

PROGRESS: IDENTIFYING

SOLUTIONS

Photo: Kayla Keenan

CHAPTER 5:

GHANA ACTION PLAN

To address the prioritized bottlenecks identiﬁed in

Chapter IV, cost-eﬀective solutions in the three priority

areas were proposed, based on impact (magnitude,

speed and sustainability) and feasibility (governance,

capacity and funding availability) to accelerate pro-

gress on MDG 5 (table 7). These are deﬁned below.

5.1 IMPROVING FP COVERAGE

Key prioritized solutions

proposed:

• Procurepersonaldataassistants(PDAs)forFPdata

capture at service delivery points, stock utilization

and inventory management at all points of the sup-

ply chain and for routine and periodic monitoring.

• AddressDistrictHealthInformationManagement

System (DHIMS) bottlenecks in DHIMS-2 and roll

out training on PDAs and DHIMS at all levels of

the service delivery chain.

• Developproposalandmobilizetheinternational

community for funding.

• ImprovefundingbyadvocatingforDAstofund

maternal health interventions through the District

Development Fund.

• AdvocateforfreeFPServicesanditsinclusioninto

the NHIS package.

• ImprovecapacityofcomprehensiveFPservices

through training in comprehensive FP, including

counselling.

• IntensifypubliceducationandBCCeortsforinte-

grated maternal and child health services, through

measures such as targeting males to meet unmet

needs for FP, and education on obstetric and neo-

natal danger signs, adolescent sexual and repro-

ductive health, nutrition, gender, HIV/AIDS/STI,

etc. Target in-school and out-of-school children

and link these eﬀorts to the communication for

development framework.

• Strengthenadvocacyonculturalfactorsaecting

maternal health (speciﬁcally in the areas of FP, SD

and EmONC).

• Improveperformancemanagementsystemsor

independent review by, for instance, NGOs.

5.2 SKILLED DELIVERY

Key prioritized acceleration

solutions:

• Developgradingsystemandupgradehealthin-

stitutions accordingly (using EmONC assessment

results).

• Categorize andproviderealisticstangnorm

(based on work load analysis to provide BEmONC

at health centres and CEmONC at district hospitals).

• Sustainthenewmidwiferyschoolsandexpansion

of midwives pre-service intake and OBG ﬁeld sites.

• Sustainthecontractrecruitmentofretiredmid-

wives and medical doctors.

• Strengthenleadershipcapacityofstaatalllev-

els.

• UseEmONCassessmenttoestablishtheextentof

access and referral gaps and make recommenda-

tions to address them.

• Strengthenadvocacyonculturalfactorsaecting

maternal health.

• Establishandstrengthenanationalmultisector

Inter-Agency Coordinating Committee (ICC) on

Maternal and Newborn Health (with TOR to in-

clude ensuring implementation of recommenda-

tions from EmONC assessments).

• AdvocateforanOceoftheFirstLady/Gentleman

to champion maternal health and identify and

appoint maternal health and newborn champi-

ons including traditional leaders (chiefs, Queen

Mothers).

• StrengthentheNationalSecretariatoftheFHDto

support implementation of maternal and child

health interventions.

5.3 IMPROVING ACCESS TO

EMONC

Key prioritized solutions to

improve access to EmONC:

• Strengthencountrycoordinationofdonorsup-

port in line with National Aid Policy.

• AdvocatefortheNationalDevelopmentPlanning

Commission and the Ministry of Local Govern-

ment and Decentralization (MoLGD) to adopt ma-

ternal health indicators as part of DA performance

monitoring.

• Developproposalsandmobilizetheinternational

community for funding.

• Strengthenintersectoralcollaborationfordelivery

of maternal health services.

• Ensureimplementationofrecommendationsof

ongoing EmONC assessments.

• PeriodicandroutineassessmentofEmONCand

other essential maternal and health services (us-

ing appropriate tools, e.g., Systematic Coverage

Evaluation, National Development Planning Com-

mission monitoring framework).

• Strengthenauditsofmaternaldeathsandinsti-

tutionalize community audit of maternal deaths,

linking it with the community-based surveillance

system (which includes maintaining a records

system, holding review meetings, and decision

making to improve maternal health).

• Increaseproductionofmidwivesandtutors,and

target and train midwives and doctors to provide

maternal and newborn care services.

• Strengthenthereferralsystemtomakeitmore

responsive:

o Develop memorandum of understanding

(MOU) with transport unions to improve trans-

portation of pregnant women with complica-

tions.

o Develop MOU with communication agencies

to strengthen and roll out mobile-phone-based

emergency response linked with the maternal

health policy.

o Expand the National Ambulance Service includ-

ing DA ambulance support.

o Properly design the anaesthesia system.

• LobbyforthepassageoftheHealthBillincluding

BTS.

• StrengthenLSStrainingandbuildRegionalRe-

source Teams.

• ImproveaccesstoENBCatalllevels(includes

neonatal resuscitation, kangaroo mother care,

rooming-in).

TABLE 7 PRIORITIZED SOLUTIONS FOR ACCELERATING PROGRESS TOWARDS MDG 5 IN GHANA

Priority MDG MDG indicators Priority inter-

ventions area(s)

Prioritized bottlenecks Prioritized acceleration solution Potential partners

Goal 5: Improve Maternal

Health

Target 5a: Reduce MMR by

three quarters between

1990 and 2015

5.1 MMR

5.2 Proportion of

births attended

by skilled health

personnel

(1) Improve FP

coverage

Stock utilization and inventory management

issues (including issues relating to

incomplete data, late reporting irregular

physical count of commodities, etc.)

Procure and use PDAs for FP data capture at service delivery points and at all points

of supply chain and for routine and periodic monitoring of stock utilization and

inventory management

MoH, GHS, WHO, UNFPA,

UNICEF, USAID, DFID, GAVI

Address DHIMS bottlenecks in DHIMS-2 and roll out training on PDAs and DHIMS at all

levels of the service delivery chain

MoH, GHS, DANIDA, GF, GAVI

Inadequate funding to procure commodities

and build capacity for maternal health

1. Develop a proposal and mobilize the international community for funding

2. Advocate for DAs to fund maternal health interventions through District

Development Fund

3. Advocate for free FP services and its inclusion into the NHIS package

MoF, MOH, GHS, WHO,

UNICEF, UNFPA, UNDP,

UNAIDS

Low provider capacity in the provision of

long-term methods (IUD, implant insertions)

and poor counselling (e.g., in the use of MEC

wheel)

Inadequate supervision and monitoring

Improve capacity in comprehensive FP service provision

Training in comprehensive FP including counselling

Improved performance management systems or independent review (e.g., by NGOs)

MoH/GHS, UNFPA, PPAG,

WHO

NGO partners

Weak DA ownership and support for

maternal health interventions

Sociocultural barriers (low male involvement

including inadequate male service points,

perception of uptake of FP, and non-

receptive maternity units/FP clinics)

Fear of side eects (irregular menstruation,

amenorrhea, etc.)

Improve public awareness and understanding on FP

Intensify public education and BCC for integrated maternal and child health services

(targeting males to meet unmet needs for FP, obstetric/neonatal danger signs,

adolescent sexual and reproductive health, nutrition, gender, HIV/AIDS/STI etc.)

including targeting in-school and out-of-school children and linking these eorts with

framework

Strengthen advocacy on cultural factors aecting maternal health ( FP, SD and

EmONC)

UNFPA, PPAG, WHO, MoH/

GHS

MoH, MoWCA, GHS, UNFPA,

UNICEF, WHO, NGO partners

FBOs, CSOs

(2) Improve SD

coverage

Improper application of institutional grading

system and lack of customized stang norm

Develop grading system and upgrade health institutions accordingly (using EmONC

assessment results).

Categorize and provide realistic stang norm based on work load analysis to serve

BEmONC (health centres) and CEmONC (district hospitals)

MoH, GHS, MoFEP, MoWH,

WHO, UNFPA, WB, EU, OPEC,

bilateral donors (Japan)

Inadequate number of midwives, doctors/

OBG specialists and tutors

Sustain the new midwifery schools and expansion of midwives pre-service intake and

OBG eld sites

Sustain the contract recruitment of retired midwives and medical doctors

Strengthen leadership capacity of sta at all levels

MOH, GHS, MoFEP, MoWH,

MoE, MoESW, WHO, UNFPA,

WB, EU, OPEC, bilateral

donors

TABLE 7 PRIORITIZED SOLUTIONS FOR ACCELERATING PROGRESS TOWARDS MDG 5 IN GHANA

Priority MDG MDG indicators Priority inter-

ventions area(s)

Prioritized bottlenecks Prioritized acceleration solution Potential partners

Goal 5: Improve Maternal

Health

Target 5a: Reduce MMR by

three quarters between

1990 and 2015

5.1 MMR

5.2 Proportion of

births attended

by skilled health

personnel

(1) Improve FP

coverage

Stock utilization and inventory management

issues (including issues relating to

incomplete data, late reporting irregular

physical count of commodities, etc.)

Procure and use PDAs for FP data capture at service delivery points and at all points

of supply chain and for routine and periodic monitoring of stock utilization and

inventory management

MoH, GHS, WHO, UNFPA,

UNICEF, USAID, DFID, GAVI

Address DHIMS bottlenecks in DHIMS-2 and roll out training on PDAs and DHIMS at all

levels of the service delivery chain

MoH, GHS, DANIDA, GF, GAVI

Inadequate funding to procure commodities

and build capacity for maternal health

1. Develop a proposal and mobilize the international community for funding

2. Advocate for DAs to fund maternal health interventions through District

Development Fund

3. Advocate for free FP services and its inclusion into the NHIS package

MoF, MOH, GHS, WHO,

UNICEF, UNFPA, UNDP,

UNAIDS

Low provider capacity in the provision of

long-term methods (IUD, implant insertions)

and poor counselling (e.g., in the use of MEC

wheel)

Inadequate supervision and monitoring

Improve capacity in comprehensive FP service provision

Training in comprehensive FP including counselling

Improved performance management systems or independent review (e.g., by NGOs)

MoH/GHS, UNFPA, PPAG,

WHO

NGO partners

Weak DA ownership and support for

maternal health interventions

Sociocultural barriers (low male involvement

including inadequate male service points,

perception of uptake of FP, and non-

receptive maternity units/FP clinics)

Fear of side eects (irregular menstruation,

amenorrhea, etc.)

Improve public awareness and understanding on FP

Intensify public education and BCC for integrated maternal and child health services

(targeting males to meet unmet needs for FP, obstetric/neonatal danger signs,

adolescent sexual and reproductive health, nutrition, gender, HIV/AIDS/STI etc.)

including targeting in-school and out-of-school children and linking these eorts with

framework

Strengthen advocacy on cultural factors aecting maternal health ( FP, SD and

EmONC)

UNFPA, PPAG, WHO, MoH/

GHS

MoH, MoWCA, GHS, UNFPA,

UNICEF, WHO, NGO partners

FBOs, CSOs

(2) Improve SD

coverage

Improper application of institutional grading

system and lack of customized stang norm

Develop grading system and upgrade health institutions accordingly (using EmONC

assessment results).

Categorize and provide realistic stang norm based on work load analysis to serve

BEmONC (health centres) and CEmONC (district hospitals)

MoH, GHS, MoFEP, MoWH,

WHO, UNFPA, WB, EU, OPEC,

bilateral donors (Japan)

Inadequate number of midwives, doctors/

OBG specialists and tutors

Sustain the new midwifery schools and expansion of midwives pre-service intake and

OBG eld sites

Sustain the contract recruitment of retired midwives and medical doctors

Strengthen leadership capacity of sta at all levels

MOH, GHS, MoFEP, MoWH,

MoE, MoESW, WHO, UNFPA,

WB, EU, OPEC, bilateral

donors

Priority MDG MDG indicators Priority inter-

ventions area(s)

Prioritized bottlenecks Prioritized acceleration solution Potential partners

Poor access to health facilities in geographic,

nancial and cultural terms (e. g., CHPS,

referral systems, community systems)

Use EmONC assessment to establish the extent of access and referral gaps and make

recommendations to address them

Strengthen advocacy on cultural factors aecting maternal health

MoH, GHS, GMA, NMWC,

GMDC

Weak overall intersectoral coordination

for maternal health and risk of non-

implementation of EmONC assessment

recommendations

Establish and strengthen (ICC) on Maternal and Newborn Health (with TOR to include

ensuring implementation of recommendations from EmONC assessment)

MoH, GHS, WHO, UNFPA,

UNICEF, USAID, DFID, WB,

EU, AfDB

Advocate for Oce of the First Lady/Gentleman to champion maternal health and

identify and appoint maternal health and newborn champions including traditional

leaders (chiefs, Queen Mothers)

MoH/GHS, UNFPA, UNDP,

WHO

(3) Improve

access to

EmONC

Strengthen the National Secretariat of the FHD to support implementation of

maternal and child health interventions

GHS

Poor alignment of donor support with

government programmes, etc.)

Strengthen country coordination of donor support in line with National Aid Policy MoFEP, MOH, GHS, UN,

MDBS, core group members

Inadequate funding for capital-intensive

investments in infrastructure and equipment

(e.g., CHPS compounds, EmONC equipment)

Advocate for DAs to fund maternal health interventions through District Development

Fund

Advocate NDPC and MoLGRD to adopt maternal health indicators as part of DA

performance monitoring

MoH, NDPC, MoLGRD,

MMDA

Develop proposal and mobilize the international community for funding MoFEP, MoH, GHS, WHO,

UNICEF, UNFPA, UNDP,

UNAIDS, MMDAs

Inadequate accessibility as a result of

inadequate transportation, weak referral

system (i.e. penetration and coverage of

National Ambulance Service) and poverty

Non-implementation of recommendations of

previous EmONC assessment

Strengthen intersectoral collaboration for delivery of maternal health services

Ensure implementation of recommendations of EmONC assessments

Periodic and routine assessment of EmONC and other essential maternal and health

services (using appropriate tools, e.g., Systematic Coverage Evaluation, NDPC

monitoring framework)

Strengthen maternal deaths audit and institutionalize community maternal deaths

audit linking it with the CBS system (records system, review meetings, decision

making to improve maternal health)

MoE, transport unions,

MoLGRD, MoFEP, MMDA,

MoRH, NGOs/CSOs, ICC for

Maternal Health

Inadequate production and procurement of

skilled health workers such as midwives and

doctors, obstetricians and gynaecologists,

specialist and tutors (including for SD, IST,

anaesthesia etc.)

Increase production of midwives, tutors, and target and train midwives and doctors to

provide maternal and newborn care services

MoE, GHS, MoH, UNFPA,

USAID, MDBS group

members

Priority MDG MDG indicators Priority inter-

ventions area(s)

Prioritized bottlenecks Prioritized acceleration solution Potential partners

Poor access to health facilities in geographic,

nancial and cultural terms (e. g., CHPS,

referral systems, community systems)

Use EmONC assessment to establish the extent of access and referral gaps and make

recommendations to address them

Strengthen advocacy on cultural factors aecting maternal health

MoH, GHS, GMA, NMWC,

GMDC

Weak overall intersectoral coordination

for maternal health and risk of non-

implementation of EmONC assessment

recommendations

Establish and strengthen (ICC) on Maternal and Newborn Health (with TOR to include

ensuring implementation of recommendations from EmONC assessment)

MoH, GHS, WHO, UNFPA,

UNICEF, USAID, DFID, WB,

EU, AfDB

Advocate for Oce of the First Lady/Gentleman to champion maternal health and

identify and appoint maternal health and newborn champions including traditional

leaders (chiefs, Queen Mothers)

MoH/GHS, UNFPA, UNDP,

WHO

(3) Improve

access to

EmONC

Strengthen the National Secretariat of the FHD to support implementation of

maternal and child health interventions

GHS

Poor alignment of donor support with

government programmes, etc.)

Strengthen country coordination of donor support in line with National Aid Policy MoFEP, MOH, GHS, UN,

MDBS, core group members

Inadequate funding for capital-intensive

investments in infrastructure and equipment

(e.g., CHPS compounds, EmONC equipment)

Advocate for DAs to fund maternal health interventions through District Development

Fund

Advocate NDPC and MoLGRD to adopt maternal health indicators as part of DA

performance monitoring

MoH, NDPC, MoLGRD,

MMDA

Develop proposal and mobilize the international community for funding MoFEP, MoH, GHS, WHO,

UNICEF, UNFPA, UNDP,

UNAIDS, MMDAs

Inadequate accessibility as a result of

inadequate transportation, weak referral

system (i.e. penetration and coverage of

National Ambulance Service) and poverty

Non-implementation of recommendations of

previous EmONC assessment

Strengthen intersectoral collaboration for delivery of maternal health services

Ensure implementation of recommendations of EmONC assessments

Periodic and routine assessment of EmONC and other essential maternal and health

services (using appropriate tools, e.g., Systematic Coverage Evaluation, NDPC

monitoring framework)

Strengthen maternal deaths audit and institutionalize community maternal deaths

audit linking it with the CBS system (records system, review meetings, decision

making to improve maternal health)

MoE, transport unions,

MoLGRD, MoFEP, MMDA,

MoRH, NGOs/CSOs, ICC for

Maternal Health

Inadequate production and procurement of

skilled health workers such as midwives and

doctors, obstetricians and gynaecologists,

specialist and tutors (including for SD, IST,

anaesthesia etc.)

Increase production of midwives, tutors, and target and train midwives and doctors to

provide maternal and newborn care services

MoE, GHS, MoH, UNFPA,

USAID, MDBS group

members

Priority MDG MDG indicators Priority inter-

ventions area(s)

Prioritized bottlenecks Prioritized acceleration solution Potential partners

Inadequate accessibility as a result of

inadequate transport, poor road networks,

weak referral systems (i.e. penetration and

coverage of National Ambulance Service)

Strengthen the referral system to make it more responsive

- Develop MOU with transport unions to improve transportation of pregnant women

with complications

- Develop MOU with communication agencies to strengthen and roll out mobile-

phone-based emergency response linked with the mobile health policy

Expand the National Ambulance Service including DA ambulance support

Design proper anaethesia system

MoH/GHS, transport unions,

MoC

Lack of legal framework for BTS

Lobby for the passage of the Health Bill including BTS ICC for maternal health,

development partners

Inadequate human resource capacity and

equipment to expand coverage of LSS and

ENC services

Strengthen LSS training and build Regional Resource Teams

Improve access to ENBC at all levels(neonatal resuscitation, kangaroo mother care,

rooming-in)

MoH/GHS, development part-

ners

6160

Priority MDG MDG indicators Priority inter-

ventions area(s)

Prioritized bottlenecks Prioritized acceleration solution Potential partners

Inadequate accessibility as a result of

inadequate transport, poor road networks,

weak referral systems (i.e. penetration and

coverage of National Ambulance Service)

Strengthen the referral system to make it more responsive

- Develop MOU with transport unions to improve transportation of pregnant women

with complications

- Develop MOU with communication agencies to strengthen and roll out mobile-

phone-based emergency response linked with the mobile health policy

Expand the National Ambulance Service including DA ambulance support

Design proper anaethesia system

MoH/GHS, transport unions,

MoC

Lack of legal framework for BTS

Lobby for the passage of the Health Bill including BTS ICC for maternal health,

development partners

Inadequate human resource capacity and

equipment to expand coverage of LSS and

ENC services

Strengthen LSS training and build Regional Resource Teams

Improve access to ENBC at all levels(neonatal resuscitation, kangaroo mother care,

rooming-in)

MoH/GHS, development part-

ners

Priority MDG MDG indicators Priority inter-

ventions area(s)

Prioritized bottlenecks Prioritized acceleration solution Potential partners

Inadequate accessibility as a result of

inadequate transport, poor road networks,

weak referral systems (i.e. penetration and

coverage of National Ambulance Service)

Strengthen the referral system to make it more responsive

- Develop MOU with transport unions to improve transportation of pregnant women

with complications

- Develop MOU with communication agencies to strengthen and roll out mobile-

phone-based emergency response linked with the mobile health policy

Expand the National Ambulance Service including DA ambulance support

Design proper anaethesia system

MoH/GHS, transport unions,

MoC

Lack of legal framework for BTS

Lobby for the passage of the Health Bill including BTS ICC for maternal health,

development partners

Inadequate human resource capacity and

equipment to expand coverage of LSS and

ENC services

Strengthen LSS training and build Regional Resource Teams

Improve access to ENBC at all levels(neonatal resuscitation, kangaroo mother care,

rooming-in)

MoH/GHS, development part-

ners

6160

Priority MDG MDG indicators Priority inter-

ventions area(s)

Prioritized bottlenecks

Prioritized acceleration solution Potential partners

Inadequate accessibility as a result of

inadequate transport, poor road networks,

weak referral systems (i.e. penetration and

coverage of National Ambulance Service)

Strengthen the referral system to make it more responsive

- Develop MOU with transport unions to improve transportation of pregnant women

with complications

- Develop MOU with communication agencies to strengthen and roll out mobile-

phone-based emergency response linked with the mobile health policy

Expand the National Ambulance Service including DA ambulance support

Design proper anaethesia system

MoH/GHS, transport unions,

MoC

Lack of legal framework for BTS

Lobby for the passage of the Health Bill including BTS ICC for maternal health,

development partners

Inadequate human resource capacity and

equipment to expand coverage of LSS and

ENC services

Strengthen LSS training and build Regional Resource Teams

Improve access to ENBC at all levels(neonatal resuscitation, kangaroo mother care,

rooming-in)

MoH/GHS, development part-

ners

MDG ACCELERATION PLAN:

BUILDING A COMPACT

Photo: Kayla Keenan

CHAPTER 6:

Maternal mortality has increased in Ghana, making

the objective to reduce maternal mortality unlikely

to be fulﬁlled if current trends continue. However,

progress in some regions of the country, such as

the Northern, Western and Central regions, where

maternal mortality improved to 195.2 per 100,000

(MDG Report 2010), clearly demonstrates that Ghana

has the potential to accelerate progress on this MDG.

The Government has already accomplished major

eﬀorts in this direction by implementing two gen-

erations of the GPRS and the draft Medium-Term

National Development Policy Framework 2010–2013

as well as speciﬁc health sector policies. Particular in-

terventions put in place to address the high levels of

maternal deaths have been indicated in the previous

sections (Chapter 2, Section 2.2). However, as indica-

tors show, many obstacles to policies, ﬁnancing and

service delivery are yet to be removed.

To accelerate progress on MDG 5, the three areas

which have been chosen as particularly catalytic are:

1. Emergency obstetric and neonatal care

2. Skilled delivery coverage

3. Family planning

6.1 COUNTRY ACTION PLAN

The present MAF analysis has uncovered the most

crippling bottlenecks as well as the most eﬀective

solutions to address them in the near term to ef-

fectively and quickly scale-up the coverage of these

major interventions. However, the Government of

Ghana will not be able to implement these solutions

on its own. If these major bottlenecks to maternal

health are to be eﬀectively removed within the next

ﬁve years, the Government of Ghana will need the

support of all stakeholders who can have an impact

on maternal health — not just the MoH and the GHS,

but also other ministries and government agencies,

bilateral and multilateral donors, UN funds and agen-

cies, civil society and the private sector.

Therefore, this MAF constitutes the basis of a CAP

which intends to bring together all the partners

to be able to favourably impact upon the eﬀective

implementation and the scaling up of the three

prioritized interventions. The Government of Ghana

will be looking towards the UNCT, especially the H4,

for technical support for the formulation and imple-

mentation modalities of the solutions identiﬁed.

Additional resources will be needed, especially for

emergency obstetric care, which may be met with

the help of bilateral and multilateral donors. NGOs

and CSOs will be able to support the implementa-

tion of solutions, especially — even if not limited

to — those focusing on sensitization and advocacy

for behaviour change as well as the monitoring of

service delivery. The private sector will also be called

upon to complement the public sector service de-

livery where additional unmet needs exist. It is only

through this renewed and enhanced partnership

with clearly attributed roles and responsibilities, but-

tressed by a robust accountability framework, and

‘business as unusual’ will high maternal deaths be

reduced for the ultimate achievement of MDG 5.

This MDG 5 Action Plan does not replace existing

nationally owned planning processes and frame-

works. These will continue to be implemented to

ensure continuity, complementarity and sustain-

ability. It, rather, constitutes a subset of prioritized

actions which need to be urgently undertaken to

accelerate progress. However, to avoid duplication,

it may be useful to constitute a starting point for the

formulation of Ghana’s submission to the Secretary

General’s Initiative on Maternal and Child Health as

well as a key input into the new UNDAF (2010–2013),

currently under formulation.

Table 8 presents an overview of the CAP including

speciﬁc activities under each solution, expected part-

nerships for each, as well as the ﬁnancing envelope

necessary. The table includes current commitments

(expectations based on previous commitments,

government revenue forecasts, etc.) as well as the

ﬁnancing gap to be mobilized.

TABLE 8 GHANA ACTION PLAN

Priority

intervention

area(s)

Prioritized

interventions

Prioritized bottlenecks Prioritized acceleration solution Potential partners Total cost (USD) Available resources/

partners

Resource gap

(1) Improve FP

coverage

(a) Improving FP

commodities supply

and distribution

Stock utilization and inventory

management issues (including

issues relating to incomplete data,

late reporting irregular physical

count of commodities, etc.)

Procure and use PDAs for FP data capture at

service delivery points and at all points of

supply chain and for routine and periodic

monitoring of stock utilization and inventory

management

MoH, GHS, WHO, UNFPA, UNICEF,

USAID, DFID, GAVI

3,812,500 280,000 GAVI 3,532,500

Address DHIMS bottlenecks in DHIMS-2 and

roll out training on PDAs and DHIMS at all

levels of the service delivery chain

MoH, GHS, DANIDA, GF, GAVI 560,000 70,000

5,000

PROMPT

FOCUS

485,000

Inadequate funding to procure

commodities

1.Develop proposal and mobilize the

international community for funding

2a. Advocate for DAs to fund maternal health

interventions through District Development

Fund

2b. Advocate for free FP services and its

inclusion into the NHIS package

2c. Ensure FP commodity security (procure

contraceptives)

MoFEP, MoH, GHS, WHO, UNICEF,

UNFPA, UNDP, UNAIDS

28,000

66,660,000

5,000

29,225,000

Government of

Ghana

23,000

37,441,000

(b) Improve quality

of comprehensive FP

services

Low provider capacity for long-term

methods (IUD, implant insertions)

and poor counselling (e.g. use of

Medical Eligibility Criteria (MEC)

wheel)

Training in comprehensive FP including

counselling

MoH/GHS, UNFPA, Planned

Parenthood Association Ghana

(PPAG), WHO,

Non-govt. partners

889,600 400,000

50,000

UNFPA

Government of

Ghana

439,600

Inadequate supervision and

monitoring

Improved performance management systems

or independent review (e.g. NGOs)

TABLE 8 GHANA ACTION PLAN

Priority

intervention

area(s)

Prioritized

interventions

Prioritized bottlenecks Prioritized acceleration solution Potential partners Total cost (USD) Available resources/

partners

Resource gap

(1) Improve FP

coverage

(a) Improving FP

commodities supply

and distribution

Stock utilization and inventory

management issues (including

issues relating to incomplete data,

late reporting irregular physical

count of commodities, etc.)

Procure and use PDAs for FP data capture at

service delivery points and at all points of

supply chain and for routine and periodic

monitoring of stock utilization and inventory

management

MoH, GHS, WHO, UNFPA, UNICEF,

USAID, DFID, GAVI

3,812,500 280,000 GAVI 3,532,500

Address DHIMS bottlenecks in DHIMS-2 and

roll out training on PDAs and DHIMS at all

levels of the service delivery chain

MoH, GHS, DANIDA, GF, GAVI 560,000 70,000

5,000

PROMPT

FOCUS

485,000

Inadequate funding to procure

commodities

1.Develop proposal and mobilize the

international community for funding

2a. Advocate for DAs to fund maternal health

interventions through District Development

Fund

2b. Advocate for free FP services and its

inclusion into the NHIS package

2c. Ensure FP commodity security (procure

contraceptives)

MoFEP, MoH, GHS, WHO, UNICEF,

UNFPA, UNDP, UNAIDS

28,000

66,660,000

5,000

29,225,000

Government of

Ghana

23,000

37,441,000

(b) Improve quality

of comprehensive FP

services

Low provider capacity for long-term

methods (IUD, implant insertions)

and poor counselling (e.g. use of

Medical Eligibility Criteria (MEC)

wheel)

Training in comprehensive FP including

counselling

MoH/GHS, UNFPA, Planned

Parenthood Association Ghana

(PPAG), WHO,

Non-govt. partners

889,600 400,000

50,000

UNFPA

Government of

Ghana

439,600

Inadequate supervision and

monitoring

Improved performance management systems

or independent review (e.g. NGOs)

Priority

intervention

area(s)

Prioritized

interventions

Prioritized bottlenecks Prioritized acceleration solution Potential partners Total cost (USD) Available resources/

partners

Resource gap

for FP services

Weak DA ownership and support

for maternal health interventions

Sociocultural barriers (low male

involvement including inadequate

male service points, perception of

uptake of FP, and non-receptive

maternity units/FP clinics)

Fear of side eects (irregular

menstruation, amenorrhea, etc.)

1. Intensify public education and BCC for

integrated maternal and child health services

(targeting males to meet unmet needs for FP,

obstetric/neonatal danger signs, adolescent

sexual and reproductive health, nutrition,

gender, HIV/AIDS/STI, etc.) including targeting

in-school and out-of-school children and link

with C4D framework

2. Strengthen advocacy on cultural factors

aecting maternal health (FP, SD and EmONC)

3. Advocate for free FP Sservices and its

inclusion into the NHIS package

UNFPA, PPAG, WHO, MoH/GHS,

Ministry of Women and Children’s

Aairs (MoWCA), GHS, UNFPA,

UNICEF, WHO, NGO partners

Faith-based organizations, CSOs

242,500

1,541,000

120,000

975,000

UNICEF, John

Hopkins University

(JHU)

ORIO, Government

of Ghana

566,000

(2) Improve SD

coverage

(a) Improve

monitoring of all

stages of labour

and the care of the

newborn and the

postnatal period

Improper application of

institutional grading system and

lack of customized stang norm

Develop grading system and upgrade health

institutions accordingly (using EmONC

assessment results).

Categorize and provide realistic stang

norm, based on work load analysis to provide

BEmONC (health centres) and CEmONC

(district hospitals)

MoH, GHS, MoFEP, MoWHW, WHO,

UNFPA, WB, EU, OPEC, bilateral

donors (Japan)

26,094,000

28,000

17,204,000

28,000

Government of

Ghana, Health

Fund

Government of

Ghana

8,890,000

Inadequate midwives, doctors,

obstetricians, gynaecologists,

specialists and tutors

Sustain new midwifery schools and expansion

of midwives pre-service intake and OBG eld

sites

Sustain the contract recruitment of retired

midwives and medical doctors

Strengthen leadership capacity of sta at all

levels

MoH, GHS, MoFEP, MoWHW, MoE,

MoESW, WHO, UNFPA, WB, EU,

OPEC, bilateral donors

14,000,000

2,080,000

7,500,000

200,000

Government of

Ghana, Health

Fund

GAVI

6,500,000

1,880,000

(b) Maintain the

implementation of

the Free Maternal

Delivery policy in line

with the NHIS

Lack of funding Develop proposal and mobilize the

international community for funding

Advocate for DAs to fund maternal health

interventions through District Development

Fund

strengthen referral

and community

support systems to

address obstetric

emergencies

Poor targeting of CHPS

Inadequate funding for capital-

intensive investments in

infrastructure and equipment

Use EmONC assessment to establish the

extent of access and referral gaps and make

recommendations to address them

MoH, GHS, Ghana Medical

Association (GMA), Nurses and

Midwives Council (MMC), Ghana

Medical and Dental Council

(GMDC)

20,000 20,000 Government of

Ghana

(d) Extend the

reach of integrated

package of service

provision through

HIRD approach

Weak overall inter-sectoral

coordination for maternal health

and Risk of non-implementation

of EmONC assessment

recommendation

Establish and strengthen ICC on Maternal and

Newborn Health (with TOR to include ensuring

implementation of recommendations from

EmONC Assessment)

MoH, GHS, WHO, UNFPA, UNICEF,

USAID, DFID, WB, EU, AfDB

40,000 20,000 UNFPA,

Government of

Ghana

20,000

5) Integrated package of services through HIRD includes some of elements of FP, SD and EmONC.

Priority

intervention

area(s)

Prioritized

interventions

Prioritized bottlenecks Prioritized acceleration solution Potential partners Total cost (USD) Available resources/

partners

Resource gap

for FP services

Weak DA ownership and support

for maternal health interventions

Sociocultural barriers (low male

involvement including inadequate

male service points, perception of

uptake of FP, and non-receptive

maternity units/FP clinics)

Fear of side eects (irregular

menstruation, amenorrhea, etc.)

1. Intensify public education and BCC for

integrated maternal and child health services

(targeting males to meet unmet needs for FP,

obstetric/neonatal danger signs, adolescent

sexual and reproductive health, nutrition,

gender, HIV/AIDS/STI, etc.) including targeting

in-school and out-of-school children and link

with C4D framework

2. Strengthen advocacy on cultural factors

aecting maternal health (FP, SD and EmONC)

3. Advocate for free FP Sservices and its

inclusion into the NHIS package

UNFPA, PPAG, WHO, MoH/GHS,

Ministry of Women and Children’s

Aairs (MoWCA), GHS, UNFPA,

UNICEF, WHO, NGO partners

Faith-based organizations, CSOs

242,500

1,541,000

120,000

975,000

UNICEF, John

Hopkins University

(JHU)

ORIO, Government

of Ghana

566,000

(2) Improve SD

coverage

(a) Improve

monitoring of all

stages of labour

and the care of the

newborn and the

postnatal period

Improper application of

institutional grading system and

lack of customized stang norm

Develop grading system and upgrade health

institutions accordingly (using EmONC

assessment results).

Categorize and provide realistic stang

norm, based on work load analysis to provide

BEmONC (health centres) and CEmONC

(district hospitals)

MoH, GHS, MoFEP, MoWHW, WHO,

UNFPA, WB, EU, OPEC, bilateral

donors (Japan)

26,094,000

28,000

17,204,000

28,000

Government of

Ghana, Health

Fund

Government of

Ghana

8,890,000

Inadequate midwives, doctors,

obstetricians, gynaecologists,

specialists and tutors

Sustain new midwifery schools and expansion

of midwives pre-service intake and OBG eld

sites

Sustain the contract recruitment of retired

midwives and medical doctors

Strengthen leadership capacity of sta at all

levels

MoH, GHS, MoFEP, MoWHW, MoE,

MoESW, WHO, UNFPA, WB, EU,

OPEC, bilateral donors

14,000,000

2,080,000

7,500,000

200,000

Government of

Ghana, Health

Fund

GAVI

6,500,000

1,880,000

(b) Maintain the

implementation of

the Free Maternal

Delivery policy in line

with the NHIS

Lack of funding Develop proposal and mobilize the

international community for funding

Advocate for DAs to fund maternal health

interventions through District Development

Fund

strengthen referral

and community

support systems to

address obstetric

emergencies

Poor targeting of CHPS

Inadequate funding for capital-

intensive investments in

infrastructure and equipment

Use EmONC assessment to establish the

extent of access and referral gaps and make

recommendations to address them

MoH, GHS, Ghana Medical

Association (GMA), Nurses and

Midwives Council (MMC), Ghana

Medical and Dental Council

(GMDC)

20,000 20,000 Government of

Ghana

(d) Extend the

reach of integrated

package of service

provision through

HIRD approach

Weak overall inter-sectoral

coordination for maternal health

and Risk of non-implementation

of EmONC assessment

recommendation

Establish and strengthen ICC on Maternal and

Newborn Health (with TOR to include ensuring

implementation of recommendations from

EmONC Assessment)

MoH, GHS, WHO, UNFPA, UNICEF,

USAID, DFID, WB, EU, AfDB

40,000 20,000 UNFPA,

Government of

Ghana

20,000

Priority

intervention

area(s)

Prioritized

interventions

Prioritized bottlenecks Prioritized acceleration solution Potential partners Total cost (USD) Available resources/

partners

Resource gap

Advocate for Oce of the First Lady/

Gentleman to Champion maternal health and

identify and appoint maternal health and

newborn champions including traditional

leaders (chiefs, Queen Mothers)

MoH/GHS, UNFPA, UNDP, WHO 100,000 30,000 Government of

Ghana

70,000

Strengthen the National Secretariat of the

FHD to support implementation of maternal

and child health interventions

GHS 100,000 40,000 WHO, UNICEF,

Government of

Ghana

60,000

(3) Improve

access to

EmONC

(a) Scale up

procurement and

improve distribution

of BEmONC and

CEmONC equipment

to health centres and

hospitals respectively

Poor alignment of donor support

with government programmes

Strengthen country coordination of donor

support in line with National Aid Policy

MoFEP, MoH, GHS, UN, core

members of MDBS Group

- - -

Inadequate funding for capital-

intensive investments in

infrastructure and equipment

(e.g., CHPS compounds, EmONC

equipment)

Advocate for DAs to fund maternal health

interventions through District Development

Fund

Advocate NDPC and MoLGRD to adopt

maternal health indicators as part of DA

performance monitoring

MoH, NDPC, MoLGRD, MMDA 50,000

100,000

10,000

20,000

Government of

Ghana

Government of

Ghana

40,000

80,000

Develop proposal and mobilize the

international community for funding

MoFEP, MoH, GHS, WHO, UNICEF,

UNFPA, UNDP, UNAIDS, MMDA

- - -

Inadequate accessibility as a result

of inadequate transportation, weak

referral systems(i.e. penetration and

coverage of National Ambulance

Service) and poverty

Non-implementation of

recommendations of previous

EmONC assessment

Strengthen intersectoral collaboration for

delivery of maternal health services

Ensure implementation of recommendations

of EmONC assessments

Periodic and routine assessment of EmONC

and other essential maternal and health

services (using appropriate tools, e.g.,

Systematic Coverage Evaluation, NDPC

monitoring framework)

Strengthen maternal deaths audit and

institutionalize community maternal deaths

auditing, linking it with the CBS systems

(records system, review meetings, decision

making to improve maternal health)

MoE, transport unions, MoLGRD,

MoFEP, MMDA, MoRHW, NGOs,

CSOs, ICC for Maternal Health

9,240,000 4,620,000 Government of

Ghana, Health

Fund

4,620,000

Priority

intervention

area(s)

Prioritized

interventions

Prioritized bottlenecks Prioritized acceleration solution Potential partners Total cost (USD) Available resources/

partners

Resource gap

Advocate for Oce of the First Lady/

Gentleman to Champion maternal health and

identify and appoint maternal health and

newborn champions including traditional

leaders (chiefs, Queen Mothers)

MoH/GHS, UNFPA, UNDP, WHO 100,000 30,000 Government of

Ghana

70,000

Strengthen the National Secretariat of the

FHD to support implementation of maternal

and child health interventions

GHS 100,000 40,000 WHO, UNICEF,

Government of

Ghana

60,000

(3) Improve

access to

EmONC

(a) Scale up

procurement and

improve distribution

of BEmONC and

CEmONC equipment

to health centres and

hospitals respectively

Poor alignment of donor support

with government programmes

Strengthen country coordination of donor

support in line with National Aid Policy

MoFEP, MoH, GHS, UN, core

members of MDBS Group

- - -

Inadequate funding for capital-

intensive investments in

infrastructure and equipment

(e.g., CHPS compounds, EmONC

equipment)

Advocate for DAs to fund maternal health

interventions through District Development

Fund

Advocate NDPC and MoLGRD to adopt

maternal health indicators as part of DA

performance monitoring

MoH, NDPC, MoLGRD, MMDA 50,000

100,000

10,000

20,000

Government of

Ghana

Government of

Ghana

40,000

80,000

Develop proposal and mobilize the

international community for funding

MoFEP, MoH, GHS, WHO, UNICEF,

UNFPA, UNDP, UNAIDS, MMDA

- - -

Inadequate accessibility as a result

of inadequate transportation, weak

referral systems(i.e. penetration and

coverage of National Ambulance

Service) and poverty

Non-implementation of

recommendations of previous

EmONC assessment

Strengthen intersectoral collaboration for

delivery of maternal health services

Ensure implementation of recommendations

of EmONC assessments

Periodic and routine assessment of EmONC

and other essential maternal and health

services (using appropriate tools, e.g.,

Systematic Coverage Evaluation, NDPC

monitoring framework)

Strengthen maternal deaths audit and

institutionalize community maternal deaths

auditing, linking it with the CBS systems

(records system, review meetings, decision

making to improve maternal health)

MoE, transport unions, MoLGRD,

MoFEP, MMDA, MoRHW, NGOs,

CSOs, ICC for Maternal Health

9,240,000 4,620,000 Government of

Ghana, Health

Fund

4,620,000

Priority

intervention

area(s)

Prioritized

interventions

Prioritized bottlenecks Prioritized acceleration solution Potential partners Total cost (USD) Available resources/

partners

Resource gap

Inadequate production and

procurement of skilled health

workers including midwives,

doctors, obstetricians,

gynaecologists specialist and tutors

(covers also SD IST, Anaesthesia,

etc.)

Increase production of midwives and tutors,

and target and train midwives and doctors to

provide maternal and newborn care services

MoE, GHS, MoH, UNFPA, USAID,

MDBS group members

350,000 200,000 Government of

Ghana

150,000

Inadequate accessibility as a result

of inadequate transport, poor road

networks, weak referral systems

(i.e. penetration and coverage of

National Ambulance Service)

Strengthen the referral system to make it

more responsive

• Develop MOU with transport unions to

improve transportation of pregnant women

with complication

• Develop MOU with communication agencies

to strengthen and roll out of mobile-phone-

based emergency response linked with the

mobilehealth policy

• Expand the National Ambulance Service

including DA ambulance support

• Design proper anaesthesia system

MoH/GHS, transport unions, MoC

500,000

100,000

30,000,000

125,000

25,000,000

DAs

Government of

Ghana

375,000

100,000

5,000,000

(b) Improve referral

and strengthen BTS in

line with the National

Blood Transfusion

Policy

Lack of legal framework for (BTS) Lobby for the passage of the Health Bill

including BTS

ICC for Maternal Health,

development partners

training and build

Regional Resource

Teams

Inadequate human resource

capacity and equipment to expand

coverage of LSS and ENC services

Strengthen LSS training and build Regional

Resource Teams

Improve access to ENBC services at all levels

(neonatal resuscitation, kangaroo mother

care, rooming-in)

MoH/GHS, development partners 768,000 300,000 Health partners,

Government of

Ghana

468,000

153,491,100 86,447,000 70,740,100

Priority

intervention

area(s)

Prioritized

interventions

Prioritized bottlenecks Prioritized acceleration solution Potential partners Total cost (USD) Available resources/

partners

Resource gap

Inadequate production and

procurement of skilled health

workers including midwives,

doctors, obstetricians,

gynaecologists specialist and tutors

(covers also SD IST, Anaesthesia,

etc.)

Increase production of midwives and tutors,

and target and train midwives and doctors to

provide maternal and newborn care services

MoE, GHS, MoH, UNFPA, USAID,

MDBS group members

350,000 200,000 Government of

Ghana

150,000

Inadequate accessibility as a result

of inadequate transport, poor road

networks, weak referral systems

(i.e. penetration and coverage of

National Ambulance Service)

Strengthen the referral system to make it

more responsive

• Develop MOU with transport unions to

improve transportation of pregnant women

with complication

• Develop MOU with communication agencies

to strengthen and roll out of mobile-phone-

based emergency response linked with the

mobilehealth policy

• Expand the National Ambulance Service

including DA ambulance support

• Design proper anaesthesia system

MoH/GHS, transport unions, MoC

500,000

100,000

30,000,000

125,000

25,000,000

DAs

Government of

Ghana

375,000

100,000

5,000,000

(b) Improve referral

and strengthen BTS in

line with the National

Blood Transfusion

Policy

Lack of legal framework for (BTS) Lobby for the passage of the Health Bill

including BTS

ICC for Maternal Health,

development partners

training and build

Regional Resource

Teams

Inadequate human resource

capacity and equipment to expand

coverage of LSS and ENC services

Strengthen LSS training and build Regional

Resource Teams

Improve access to ENBC services at all levels

(neonatal resuscitation, kangaroo mother

care, rooming-in)

MoH/GHS, development partners 768,000 300,000 Health partners,

Government of

Ghana

468,000

153,491,100 86,447,000 70,740,100

6.2 IMPLEMENTATION AND

MONITORING PLAN

The MDGs remain achievable by 2015 if backed by

the right policies, implementation strategies and

actions, coupled with strong political commitment,

and adequate funding and institutional capacities.

Central to the success of this Action Plan will be

the coordinated approach of implementation that

targets eﬀective service delivery for the provision of

EmONC, SD and FP.

Usually, such an eﬀort is hampered by a weak moni-

toring system, particularly in assessing the eﬀec-

tiveness of services in terms of their coverage or

outcomes at all levels. By using the appropriate tools,

for example the Systematic Coverage Evaluation tool

and the NDPC monitoring framework , it is possible

for service providers and health managers to stay

on track and remain accountable.

The collaborative and inclusive process through

which this MAF and CAP have been written are ini-

tial good steps in the right direction. The objective

of the implementation and monitoring plan — as

an integral part of the Country Action Plan — is to

follow up on commitments made and, above all,

track progress over time.

TABLE 9 GHANA MDG 5 IMPLEMENTATION AND MONITORING PLAN

Acceleration

solution/activities

Indicator IMPLEMENTATION TIME LINE

(2011–2015

Indicator for monitoring

(yearly)

Responsible MDA

(structure)

2010 2011 2012 2013 2014 2015 2010 2011 2012 2013 2014 2015

Procure and use PDAs

for FP data capture at

service delivery point

Number of subdistricts/districts using PDAs for

data capture.

Number of PDAs procured.

X X See above table

8 for responsible

partners

Address DHIMS

bottlenecks in

DHIMS-2 and roll out

training on PDAs and

DHIMS

DHIMS-2 completed.

Number of districts using DHIMS-2 for data

reporting

X X

Advocate for DAs to

fund maternal health

interventions through

District Development

Fund

Percentage of districts supporting maternal

health through DDF

X X

Develop proposal

and mobilize

the international

community for

funding

Number of successful proposals for maternal

health

X X X X X X

Periodic and routine

assessment of EmONC

and other essential

maternal health

services

Number of routine assessments done,

% HFs providing ANC/PNC

% ANC clients with 4+ visits. % ITN use; %HIV

tested; % IPT2

X X X X

TABLE 9 GHANA MDG 5 IMPLEMENTATION AND MONITORING PLAN

Acceleration

solution/activities

Indicator IMPLEMENTATION TIME LINE

(2011–2015

Indicator for monitoring

(yearly)

Responsible MDA

(structure)

2010 2011 2012 2013 2014 2015 2010 2011 2012 2013 2014 2015

Procure and use PDAs

for FP data capture at

service delivery point

Number of subdistricts/districts using PDAs for

data capture.

Number of PDAs procured.

X X See above table

8 for responsible

partners

Address DHIMS

bottlenecks in

DHIMS-2 and roll out

training on PDAs and

DHIMS

DHIMS-2 completed.

Number of districts using DHIMS-2 for data

reporting

X X

Advocate for DAs to

fund maternal health

interventions through

District Development

Fund

Percentage of districts supporting maternal

health through DDF

X X

Develop proposal

and mobilize

the international

community for

funding

Number of successful proposals for maternal

health

X X X X X X

Periodic and routine

assessment of EmONC

and other essential

maternal health

services

Number of routine assessments done,

% HFs providing ANC/PNC

% ANC clients with 4+ visits. % ITN use; %HIV

tested; % IPT2

X X X X

Acceleration

solution/activities

Indicator IMPLEMENTATION TIME LINE

(2011–2015

Indicator for monitoring

(yearly)

Responsible MDA

(structure)

2010 2011 2012 2013 2014 2015 2010 2011 2012 2013 2014 2015

Training in and

ensure the conduct

of comprehensive

FP services including

counselling

Number of sta trained X X

Intensify public

education and BCC

for integrated MCH

Services (Targeting

males to meet unmet

needs for FP, and

Obstetric/Neonatal

Danger Signs)

Contraceptive acceptor rate, % private sector

FP commodities supplumented, ratio of donor

to GOG funds for contraceptives, % of CHWs

and CHOs trained in HBLSS, number of BCC/IEC

materials,

X X X

X X

Upgrade health

institutions (using

EmONC assessment

results), categorize

and provide realistic

stang norm (based

on work load analysis

to provide BEmONC

(health centres) and

CEmONC (district

hospitals)

Number of health facilities upgraded

% facilities oering BEOC

% districts oering CEOC

% districts with transfusion service

Improve supervision

and monitoring

(horizontal etc.)

Improved quality of care according to national

standards

X X X

Sustain new

midwifery schools

and expansion of

midwives pre-service

intake and OBG eld

sites

New midwifery schools established.

Number of enrolled midwives in training

institutions

X X X

Use EmONC

assessment to

establish the extent

of access and

referral gaps, make

recommendations

and address them

Access gaps established X

Acceleration

solution/activities

Indicator IMPLEMENTATION TIME LINE

(2011–2015

Indicator for monitoring

(yearly)

Responsible MDA

(structure)

2010 2011 2012 2013 2014 2015 2010 2011 2012 2013 2014 2015

Training in and

ensure the conduct

of comprehensive

FP services including

counselling

Number of sta trained X X

Intensify public

education and BCC

for integrated MCH

Services (Targeting

males to meet unmet

needs for FP, and

Obstetric/Neonatal

Danger Signs)

Contraceptive acceptor rate, % private sector

FP commodities supplumented, ratio of donor

to GOG funds for contraceptives, % of CHWs

and CHOs trained in HBLSS, number of BCC/IEC

materials,

X X X

X X

Upgrade health

institutions (using

EmONC assessment

results), categorize

and provide realistic

stang norm (based

on work load analysis

to provide BEmONC

(health centres) and

CEmONC (district

hospitals)

Number of health facilities upgraded

% facilities oering BEOC

% districts oering CEOC

% districts with transfusion service

Improve supervision

and monitoring

(horizontal etc.)

Improved quality of care according to national

standards

X X X

Sustain new

midwifery schools

and expansion of

midwives pre-service

intake and OBG eld

sites

New midwifery schools established.

Number of enrolled midwives in training

institutions

X X X

Use EmONC

assessment to

establish the extent

of access and

referral gaps, make

recommendations

and address them

Access gaps established X

Acceleration

solution/activities

Indicator IMPLEMENTATION TIME LINE

(2011–2015

Indicator for monitoring

(yearly)

Responsible MDA

(structure)

2010 2011 2012 2013 2014 2015 2010 2011 2012 2013 2014 2015

Establish and

strengthen ICC

on Maternal and

Newborn Health

with TOR to

include ensuring

implementation of

recommendations

from EmONC

assessment

ICC established.

Quarterly meetings held

X X X X

Advocate for Oce

of the First Lady/

Gentleman to

champion maternal

health and identify

and appoint maternal

health champions

Oce of First Lady/Gentleman appoints

champion for maternal health

Strengthen country

coordination of donor

support in line with

National Aid Policy

Proper coordination of donor support as per

National Aid Policy

X X X X X

Advocate for DAs to

fund maternal health

interventions through

District Development

Fund

**Repeated above X X

Develop proposal

and mobilize

the international

community for

funding

**Repeated above X X X X X

Strengthen

intersectoral

collaboration

for delivery of

maternal health

services (Ministries,

departments,

agencies, partners,

Trade Union

Congress)

Number of intersectoral meetings held on

maternal health

X X X X X

Acceleration

solution/activities

Indicator IMPLEMENTATION TIME LINE

(2011–2015

Indicator for monitoring

(yearly)

Responsible MDA

(structure)

2010 2011 2012 2013 2014 2015 2010 2011 2012 2013 2014 2015

Establish and

strengthen ICC

on Maternal and

Newborn Health

with TOR to

include ensuring

implementation of

recommendations

from EmONC

assessment

ICC established.

Quarterly meetings held

X X X X

Advocate for Oce

of the First Lady/

Gentleman to

champion maternal

health and identify

and appoint maternal

health champions

Oce of First Lady/Gentleman appoints

champion for maternal health

Strengthen country

coordination of donor

support in line with

National Aid Policy

Proper coordination of donor support as per

National Aid Policy

X X X X X

Advocate for DAs to

fund maternal health

interventions through

District Development

Fund

**Repeated above X X

Develop proposal

and mobilize

the international

community for

funding

**Repeated above X X X X X

Strengthen

intersectoral

collaboration

for delivery of

maternal health

services (Ministries,

departments,

agencies, partners,

Trade Union

Congress)

Number of intersectoral meetings held on

maternal health

X X X X X

Acceleration

solution/activities

Indicator IMPLEMENTATION TIME LINE

(2011–2015

Indicator for monitoring

(yearly)

Responsible MDA

(structure)

2010 2011 2012 2013 2014 2015 2010 2011 2012 2013 2014 2015

Increase production

of midwives/tutors,

and target and

train midwives, and

doctors to provide

maternal and

newborn care services

Number of sta produced X X X X X

Strengthen the

referral system

to make it more

responsive

- MOU with transport

unions

-Expansion of

National Ambulance

Service

Improved referral system as per national

guidelines.

Number of districts with MOU with transport

unions

X X X X X

Lobby for the passage

of the Health Bill

including BTS

Passage of health bills X

Strengthen LSS

training and build

Regional Resource

Teams

Number of key sta trained in LSS.

Number of skilled attendants

X X

NB: Use sector-wide indicators.

7978

Acceleration

solution/activities

Indicator IMPLEMENTATION TIME LINE

(2011–2015

Indicator for monitoring

(yearly)

Responsible MDA

(structure)

2010 2011 2012 2013 2014 2015 2010 2011 2012 2013 2014 2015

Increase production

of midwives/tutors,

and target and

train midwives, and

doctors to provide

maternal and

newborn care services

Number of sta produced X X X X X

Strengthen the

referral system

to make it more

responsive

- MOU with transport

unions

-Expansion of

National Ambulance

Service

Improved referral system as per national

guidelines.

Number of districts with MOU with transport

unions

X X X X X

Lobby for the passage

of the Health Bill

including BTS

Passage of health bills X

Strengthen LSS

training and build

Regional Resource

Teams

Number of key sta trained in LSS.

Number of skilled attendants

X X

NB: Use sector-wide indicators.

Acceleration

solution/activities

Indicator IMPLEMENTATION TIME LINE

(2011–2015

Indicator for monitoring

(yearly)

Responsible MDA

(structure)

2010 2011 2012 2013 2014 2015 2010 2011 2012 2013 2014 2015

Increase production

of midwives/tutors,

and target and

train midwives, and

doctors to provide

maternal and

newborn care services

Number of sta produced X X X X X

Strengthen the

referral system

to make it more

responsive

- MOU with transport

unions

-Expansion of

National Ambulance

Service

Improved referral system as per national

guidelines.

Number of districts with MOU with transport

unions

X X X X X

Lobby for the passage

of the Health Bill

including BTS

Passage of health bills X

Strengthen LSS

training and build

Regional Resource

Teams

Number of key sta trained in LSS.

Number of skilled attendants

X X

NB: Use sector-wide indicators.

7978

Acceleration

solution/activities

Indicator IMPLEMENTATION TIME LINE

(2011–2015

Indicator for monitoring

(yearly)

Responsible MDA

(structure)

2010 2011 2012 2013

2014 2015 2010 2011 2012 2013 2014 2015

Increase production

of midwives/tutors,

and target and

train midwives, and

doctors to provide

maternal and

newborn care services

Number of sta produced X X X

X X

Strengthen the

referral system

to make it more

responsive

- MOU with transport

unions

-Expansion of

National Ambulance

Service

Improved referral system as per national

guidelines.

Number of districts with MOU with transport

unions

X X X

X X

Lobby for the passage

of the Health Bill

including BTS

Passage of health bills X

Strengthen LSS

training and build

Regional Resource

Teams

Number of key sta trained in LSS.

Number of skilled attendants

X X

NB: Use sector-wide indicators.

ANNEXES

Photo: Kayla Keenan

ANNEX 1: POLICY DOCUMENTS

AND REPORTS

Road map for accelerating the attainment of

the MDGs related to maternal and newborn

health in Ghana

Road map for repositioning FP in Ghana

2006–2010

Prevention and management of unsafe

abortion: comprehensive abortion services,

standards and protocol

4. National reproductive health service, policy

and standards

5. MoH 2010 POW

Improving access to quality care in FP, medi-

cal eligibility criteria for contraceptive use

(MEC Wheel)

Revised child health policy 2007–2015, Dr.

Aboagye/UNICEF

Reproductive health strategic plan 2007–

2011

9. Safe motherhood protocol

10. FP protocol

11.

Ghana Reproductive Health Strategic Plan

(2006–2010)

12.

Creation of Inter-Ministerial Task Force for

Maternal Mortality Reduction (2008)

13.

Creation of Making Pregnancy Safer Task

Force

14.

‘REDUCE’ Model for improving maternal and

newborn survival in Ghana

15.

Proposal by UNICEF, UNFPA and WHO on

achieving the health MDGs in Ghana (2009,

enclosed)

16.

CARMMA (AU Campaign on Accelerated Re-

duction of Maternal Mortality, 2009)

17. Development of Emergency Obstetric and

Newborn Care (EmONC) Needs Assessment

(2010)

18.

Minister of Health declaring maternal mortal-

ity a national emergency (2008)

19. Report on the National Consultative Meet-

ing on the Reduction of Maternal Mortality

in Ghana (2008)

20.

Launch of the Commission of Women’s

Health in the African Region (2010)

NATIONAL (GOVERNMENT) POLICY

DOCUMENTS

21.

Ghana Poverty Reduction Strategy 2003–

2005

22.

Growth and Poverty Reduction Strategy

(GPRS II) (2006–2008)

23.

The millennium villages project Bonsaaso

Ghana cluster

24.

Draft Medium-Term National Develop-

ment Policy Framework 2010–2013

GENERAL HEALTH POLICY DOCUMENTS

25. National health policy

26. MoH gender policy

27. Adolescent reproductive health policy

28. National e-health strategy

29.

Ghana health sector ﬁve-year programme of

work 2002–2006, an in-depth review of the

health sector response to maternal mortality

in Ghana by 2003

30.

Third health sector ﬁve-year plan 2007-2011

31.

GHS ﬁve-year strategic framework for service

delivery 2007–2011

32.

Health sector medium-term development

plan 2010–2013

33. Health Sector Policy and Annual Workplans

34. Guidelines on Nutrition

35. PMTC plus guidelines

36. Early Infant diagnosis (EID) 2009

37.

Policies on orphans and vulnerable children

(OVCs)

REPORTS

38.

A paper on safe motherhood programme in

Ghana, prepared for Africa population com-

mission: West African regional conference

6–9 November 2006

39.

Health sector in Ghana: Facts and ﬁgures,

2009

40. Annual Report RCH 2007

41.

Annual Report FHD 2008, 2009

42.

Monitoring visit report for 2008 HIRD imple-

mentation in all regions

43.

Institutional analysis of safe motherhood

policy-making in Ghana

44.

Selected practices recommendation for con-

traceptive use 2008 update

45.

MEC wheel evaluation report WHO, Dr

Charles Fleisher

46. Strategic assessment of abortion care serv-

ices in Ghana

47. Readiness for abortion care services

48.

Time to take charge — advocacy tool for

resource mobilization

49. EmONC baseline report, 2005

50.

Annual Progress Reports of the GPRS I & II

(2005, 2006, 2007, 2008, 2009)

51. Demographic Health Survey (2003, 2008)

52.

Ghana Living Standards Survey (1999, 2006)

53. Ghana Maternal Health Survey (2007)

54.

Evaluation reports with reference to maternal

health care delivery

55. MDG Reports (2002, 2004, 2006, draft 2010

editions)

56.

Millennium Villages Project (MVP) Assess-

ment

57. Millennium Villages Project (MVP) reports

58.

WHO Access meeting/Midwifery training

and Pre-service curriculum reviews

59. MEC 2008 Update (ppt)

60.

Ghana maternal health survey 2007 dissemi-

nation (ppt)

61. Maternal mortality in Ghana (ppt)

62.

Reproductive health and maternal mortality

in Ghana (ppt)

63. Contraceptive security issues at facilities re-

view

64. HIRD progress report

65. Microeconomics in health

66. Health Sector Annual reports

67.

Citizen Assessment Report of the

NHIS

68.

Senior oﬃcers of MOH/GHS at various levels

of health care system

ANNEX 2: QUESTIONNAIRE

ADMINISTERED TO DDHS GROUP

Dear DDHS

The high maternal mortality rate in Ghana has been

of great concern to decision makers resulting in ma-

ternal being declared emergency in July, 2008. The

MAF is aimed at supporting national government

and her partners to better understand the deep-

rooted causes militating against positive outcomes

in maternal health care.

In this regard, your experience and expertise is be-

ing solicited.

In your opinion

1) What are some of the key existing policies on

Maternal Health in Ghana?

2) What are some of the key existing interventions

on Maternal Health in Ghana?

3) What are the gaps in the existing policies and

interventions on Maternal Health Care in Ghana?

4) What are the major bottlenecks (challenges)

to the eﬀective implementation of the key in-

terventions for accelerating progress on MDG5

in Ghana?

5) What are the key cost eﬀective solutions that

can accelerate progress of Maternal Health Care

in Ghana?

ANNEX 3: MDG 5 DOCUMENTS,

RECOMMENDATIONS AND

LEVEL OF IMPLEMENTATION

MAF TECHNICAL TEAM WORKING SESSION, 913 AUGUST 2010 AT GHS, ACCRA

No Document Year Recommendations Level of implementation Possible negative eect on MDG5

attainment

Comment

Partially Fully Unclear/nil Minimal Moderate High

1 Improving access to quality care

in FP: medical eligibility criteria for

contraceptive use (MEC Wheel)

To be used by all FP service points X X Not generally

available

GHS/Partners “revised Contraceptives

Procurement Tables (CPTs)” in March 2006

X X Level of

availability and

use not certain

2 2010 MOH Programme of Work 2010

3 A road map for repositioning FP in

Ghana, 2006–2010

2006 X

Expand service delivery sites X X

Expand resource mobilization and

contraceptive commodities

X X

4 Road Map for Accelerating the

attainment of the MDGs Related

Maternal and Neonatal Health In

Ghana 2007-2011

Track the following indicators:

-minimum of four visits per ANC client

- % facilities oering BEOC

- % districts oering CEOC

- % districts with BTS

- of HFs oering CAC

- % of facilities with good referral system for

maternal and neonatal health

5 Accelerating improvements in

maternal and newborn health in

northern Ghana, needs assessment

report, Oct 2005, UNICEF, UNFPA,

KNUST, GHS-RCH

Develop system to provide and track IST in

LSS for midwives to provide BEmOC?

MAF TECHNICAL TEAM WORKING SESSION, 913 AUGUST 2010 AT GHS, ACCRA

No Document Year Recommendations Level of implementation Possible negative eect on MDG5

attainment

Comment

Partially Fully Unclear/nil Minimal Moderate High

1 Improving access to quality care

in FP: medical eligibility criteria for

contraceptive use (MEC Wheel)

To be used by all FP service points X X Not generally

available

GHS/Partners “revised Contraceptives

Procurement Tables (CPTs)” in March 2006

X X Level of

availability and

use not certain

2 2010 MOH Programme of Work 2010

3 A road map for repositioning FP in

Ghana, 2006–2010

2006 X

Expand service delivery sites X X

Expand resource mobilization and

contraceptive commodities

X X

4 Road Map for Accelerating the

attainment of the MDGs Related

Maternal and Neonatal Health In

Ghana 2007-2011

Track the following indicators:

-minimum of four visits per ANC client

- % facilities oering BEOC

- % districts oering CEOC

- % districts with BTS

- of HFs oering CAC

- % of facilities with good referral system for

maternal and neonatal health

5 Accelerating improvements in

maternal and newborn health in

northern Ghana, needs assessment

report, Oct 2005, UNICEF, UNFPA,

KNUST, GHS-RCH

Develop system to provide and track IST in

LSS for midwives to provide BEmOC?

No Document Year Recommendations Level of implementation Possible negative eect on MDG5

attainment

Comment

Partially Fully Unclear/nil Minimal Moderate High

6 National reproductive health service

policy and standards,

2003, GHS

Decentralize greater proportion of funds for

reproductive health shall be decentralized to

the district level

X X

Clinical skills training, X X

Equipment supply X X

Build partnerships X X

Integrate X X

7 A paper on safe motherhood

programme in Ghana, Nov 2006, Odoi

Agyarko et al.

2006

8 Title: Ministry of Health (2009), Health

Sector Gender Policy, April 2009

Address gender inequalities in health service

delivery to ensures integration of gender

issues in service provision

9 Title: Gender Issues Paper (Second

Draft). Ministry of Health, Agyare-

Kwabi

No Document Year Recommendations Level of implementation Possible negative eect on MDG5

attainment

Comment

Partially Fully Unclear/nil Minimal Moderate High

6 National reproductive health service

policy and standards,

2003, GHS

Decentralize greater proportion of funds for

reproductive health shall be decentralized to

the district level

X X

Clinical skills training, X X

Equipment supply X X

Build partnerships X X

Integrate X X

7 A paper on safe motherhood

programme in Ghana, Nov 2006, Odoi

Agyarko et al.

2006

8 Title: Ministry of Health (2009), Health

Sector Gender Policy, April 2009

Address gender inequalities in health service

delivery to ensures integration of gender

issues in service provision

9 Title: Gender Issues Paper (Second

Draft). Ministry of Health, Agyare-

Kwabi

ANNEX 4: REFERENCES

Ghana Poverty Reduction Strategy 2003–

2005: An Agenda for Growth and Prosper-

ity. Volume 1, Analysis and Policy Statement.

National Development Planning Commission,

February 2003

This is a comprehensive national development pol-

icy framework in support of poverty reduction and

growth. The document links HIV/AIDS strongly with

poverty and deﬁnes interventions to prevent new

infections of HIV, promote safer sex, prevent Mother

to Child Transmission, ensure safe blood and blood

products and improve STI management (target:

base year 2000 to 24 percent by 2005). It also aims

at providing a continuum of care or people living

with HIV/AIDS (PLWHA) and their families, continu-

ous supportive counseling and palliative care in the

household and community and the management

of opportunistic infections target: base year 2000

of 5.8 percent to 15 percent by 2005 for women

and 2000 of 15.4 percent to 25 percent by 2005 for

men ). Other interventions laid out include eﬀective

institutional foundation (target: base year 2000 to 24

percent, 2005), joint interventions on health care and

safe water and environmental sanitation, access to

quality health and nutrition services, susstainable

ﬁnancing arrangements that protect the poor, and

eﬃciency in service delivery with the following tar-

gets: IMR 57/1,000lbs (2000) to 50/1000 (2005); MMR

200/100,000lbs (2000) and 160/100,000lbs (2005)

and SD 49 percent (2000) to 55 percent (2005).

Growth and Poverty Reduction Strategy (GRSP

II) (2006–2009), Volume 1, Policy Framework,

November 2005, National Development Plan-

ning Commission

Policy issues: The policy goal was to attain middle-

income status (with a per capita income of at least

$1,000) by the year 2015 within a decentralized and

democratic environment. The main issues include a

broad national development framework, health care,

safe water and environmental sanitation, access to

quality health and nutrition services, sustainable

ﬁnancing arrangements that protect the poor, and

eﬃciency in service delivery. The intervention and

targets were the MDGs 4 and 5 and the development

and implementation of high-impact yielding strate-

gies for U5M, maternal mortality, malnutrition and

redistribution of health workers in favour of deprived

areas and improvement of CHPS.

Monitoring Visit Report for 2008 HIRD imple-

mentation in all regions. (2008) GHS

The aim of this assessment was to look at HIRD im-

plementation at regional, district and subdistrict

levels. The assessment found that all regions had

trained staﬀ in LSS, usage of partographs and neo-

natal resuscitation. The main challenges were: (a)

unavailability of necessary logistics; (b) insuﬃcient

health staﬀ (quantity and quality); (c) insuﬃcient

funds; (d) lack of transportation; and (e) frequent

breakdown of motorbikes and high maintenance

costs (i.e., Jialing motorbikes).

Institutional Analysis of Safe Motherhood Policy-

Making in Ghana, IMMPACT, NMIMR, 2005

The main aim of the safe motherhood policy is to

reduce maternal mortality. It identiﬁes the following

areas to be tackled to achieve the policy objective:

(a) low health education; (b) poor monitoring; (c)

sustainability of free delivery; (d) sociocultural beliefs

and practices (leading to a delay in seeking care); (e)

institutional arrangement (dilemma of clinical care

and public health); (f ) insuﬃcient health staﬀ; and

(g) cost of services (including transportation).

Under-ve Child Health Strategy: 2007–2015.

MOH, Ghana.

This strategic document focuses on achieving MDG

4 (reduction of child mortality from 111/1000 in 2006

to 10/1000 in 2015). The key interventions identiﬁed

were antenatal care, delivery care, postnatal care,

immunizations, nutrition, treatment of child illness

and prevention of malaria.

Targets are set for focused antenatal care (FANC) and

SD: proportion of deliveries undertaken by skilled

birth attendants; 50 percent (2006) to 65 percent,

neonatal interventions and children between the

ages of 1 and 59 months.

Among the targets are increasing the following rates:

exclusive breast feeding for six months, from 54 per-

cent (2006) to 75 percent (2015); the proportion of

children aged six to 59 months who have received

a dose of vitamin A in the previous six months, from

60 percent (2006) to 90 percent (2011); the propor-

tion of children aged 12 to 23 months who are fully

vaccinated, from 64 percent (2006) to 70 percent

(2011); the proportion of children sleeping under

insecticide-treated nets the previous night from 22

percent (2006) to 55 percent (2011); the proportion

of children with fever receiving an appropriate anti-

malarial within 24 hrs, from 61 percent (2006) to 70

percent (2011); the proportion of children with wa-

tery diarrhoea receiving ORT, from 37 percent (2006)

to 60 percent (2011); the proportion of children with

watery diarrhoea receiving ORT and an appropriate

course of zinc, from 25 percent (2011); and the pro-

portion of children with suspected pneumonia who

received appropriate antibiotics, from 33 percent

(2006) to 50 percent (2011).

National e-Health Strategy, MoH

The e-Health strategy, “the combined use of electron-

ic information and communication technology in

the health sector” (WHO deﬁnition) aims to improve

access to information in support of safe, eﬃcient

and eﬀective health care delivery in a timely manner

and at the point of need. It guides the deployment

of information and communication technology at

all levels of the health system, to enable the com-

munication and exchange of information among

multi-disciplinary health teams to provide better

coordinated and seamless health care, improve the

quality and eﬃciency of decision-making to clinical

practice through better access to health informa-

tion, clinical evidence and clinical decision support

tools, and provides access to appropriately packaged

information to enable individuals to make informed

health choices to manage, control and improve per-

sonal health outcomes in all parts of the country.

For the health care provider, it is to improve their sys-

tems for patient record keeping, web-based disease

surveillance, electronic prescriptions, referral man-

agement, patient appointments and e-consultation

and remote service. It aims to beneﬁt health care

managers by improving ﬁnancial, performance, hu-

man resource and logistics management systems.

Consumers are to beneﬁt by enhanced notiﬁca-

tion systems, scheduled appointment programmes,

packaged public health messages and a health in-

formation resource network.

MoH 2010 Programme of Work, THE GHANA

HEALTH SECTOR (Going Beyond Strategy to Ac-

tion)

The goal of the health sector in the medium term

(2010–2013) is to ensure a healthy and productive

population that continues to reproduce safely.

The key issue is ensuring improved maternal and

child care. It highlights ﬁve main priorities with re-

gard to decreasing maternal and child mortality

through improved FP, SD, access to blood services,

comprehensive abortion care, neonatal care and

malnutrition. There are also strategic budgetary al-

locations for infrastructure and equipment related

to MDG 5.

Improving access to quality care in family plan-

ning: Medical eligibility criteria for contraceptive

use (MEC Wheel)

The wheel contains medical eligibility criteria and

tells providers if a woman presented with a known

medical or physical condition is able to use various

contraceptive methods safely and eﬀectively and

has recommendations for combined pills, combined

injectable contraceptive, progesterone-only pills,

implants and copper-bearing IUD. This wheel, if used

appropriately by providers, will protect women who

want to use contraceptives from infections, and pos-

sible death from cardiovascular diseases, diabetes,

cancers, hypertension and postpartum-related

health issues.

A road map for repositioning family planning in

Ghana, 2006–2010

This document aims to ensure that FP becomes

the fulcrum for strengthening and advancing re-

productive health and rights and reposition FP as

a national priority.

(It has eight elements, namely policy, advocacy, BCC,

institutional coordination and collaboration, human

resource development and capacity-building, ex-

panding access to FP services, strengthening re-

source mobilization and research, and monitoring

and evaluation.)

The rationale is to achieve a stabilized total fertility

rate, by addressing the rapidly growing population,

the persistent gaps between FP knowledge and

use, and high unmet need for FP 34 percent, 22

percent for spacing and 12 percent for limiting- DHS

2003. The document recognizes the role of FP in the

achievement of MDG 5 and states in the introduc-

tion: “There is growing concern among population

and health experts in Ghana that under the existing

scenario, the goals of the Ghana Poverty Reduction

Strategy, key elements of the Millennium Develop-

ment Goals (MDGs)… are unlikely to be achieved”.

Firm targets are to be set for CPR, TFR, MMR and IMR

as stated in page 37. A comprehensive plan is to be

prepared by the National Population Council with

MoH/GHS and NDPC, with key stakeholder respon-

sibilities deﬁned. A well coordinated and integrated

advocacy plan was developed and is expected to

be implemented. Service delivery sites, resource

mobilization and contraceptive commodities are

to be expanded and standardized formats for data

collection and analysis prepared. A comprehensive

training programme was also prepared but lack of

funding has limited its implementation.

Road map for accelerating the attainment of the

MDGs related to maternal and neonatal health

in Ghana 2007–2011

The road map provides a framework for the imple-

mentation of HIRD which uses evidence-based, feasi-

ble and cost-eﬀective interventions in resource-poor

settings to achieve accelerated reduction in maternal

and newborn deaths. The health care facility level

interventions are skilled attendance, equipment and

supplies and EmONC. The community interventions

are IEC to improve good health practices and health-

seeking behaviour and to recognize danger signs.

The objectives are to increase ANC and PNC cover-

age; increase the proportion of skilled deliveries, im-

prove access to comprehensive and basic essential

obstetric care; increase the capacity of providers to

implement appropriate ENC; expand FP providers

and services; promote individual, family and com-

munity practices to improve maternal and neonatal

health; strengthen systems and mobilize resources

for maternal and neonatal health, and referral and

HMIS systems; strengthen supervision and monitor-

ing systems; and develop and implement a research

agenda. The document outlines all strategies and

6) GHS, A road map for repositioning Family Planning in Ghana, 2006-2010.

7) GHS, Road Map for Accelerating the Attainment of the MDGs Related to Maternal and Neonatal Health In Ghana 2007-2011

interventions and identiﬁes implementing partners,

progress indicators and a budget.

National Reproductive health service policy and

standards

2003, GHS

Issues: Sets out nine priority reproductive health ar-

eas and a child-centred continuum of care approach

for integrated service delivery. These areas are:

1. Safe motherhood;

2. FP;

Prevention and management of unsafe abor-

tions and PAC;

4. Prevention and management of RTIs (STIs/

HIV/AIDS);

5. Prevention and management of infertility;

6. Prevention and management of cancer, in-

cluding breast cancer;

Response to menopausal and andropause

concerns;

Discouragement of harmful traditional prac-

tices;

9. Information and counselling.

The defined interventions are ANC, labour and

delivery care, PNC, PMTCT of HIV, IEC, aﬀordable

commodities, infertility management and dual pro-

tection. Others include prevention of unwanted

pregnancies (abortion care services, management

of abortion-related complications).

Other interventions include the prevention and con-

trol of RTI (STI, HIV/AIDS), management and support

(PLWHA), prevention of infertility, treatment of infer-

tility, social support for infertile couples, prevention

of cancer (early detection and treatment, manag-

ing the terminally ill), awareness and management

(awareness of dangers, management and rehabilita-

tion of victims) and advocacy, community mobiliza-

tion, outreach programmes and database training.

Paper on the safe motherhood programme in

Ghana, November 2006, Odoi Agyarko et al.

This paper reviews the safe motherhood programme

as it started in 1987 in Ghana, outlines its objective

and interventions, looks at progress made and chal-

lenges (funding gaps, inadequate empowerment,

weak integration) and makes recommendations

(improved maternal care services, BCEC/CEmOC,

FP, AdH, AdV etc.) for the way forward. The paper,

however, does not get to the bottom of why the

safe motherhood interventions (HE, ANC, delivery

care, PNC, FP, the prevention and management of

unsafe abortions) are not giving the required results.

Accelerating improvements in maternal and

newborn health in northern Ghana, needs as-

sessment report, October 2005, UNICEF, UNFPA,

KNUST, GHS-RCH

This needs assessment report is set against a target

of at least one comprehensive and four basic EmOC

and ENC facilities per 200,000 people (or per health

district). Most of the health facilities surveyed have

the capacity to provide EmOC and ENC services on

a 24-hour basis, but only a few actually provided

such services.

The report found that while the target was met for

EmONC, the proportion of expected complications

actually managed was low (0.6 percent). The CS rate

was low. Among the challenges listed were lack of

theatres, the absence of EMoC/ENC in most health

centres, weak referral systems, inadequate midwives

and limited training in LSS and SMI.

It was not possible to obtain information

on the following critical questions related

to EmONC and CHPS.

What proportion of district hospitals have

theatres/doctors for CEmONC?

3. What proportion of HC/SDs have midwives

and can provide BEmONC?

8) GHS, National Reproductive health service policy and standards.

What is new in the referral system in Ghana?

5. How many CHPS compounds does Ghana

have and what proportion of them have

midwives?

What is the system to provide and track IST in

LSS for midwives and how do we know what

percentage trained in the last ﬁve years?

MoH (2009). Health Sector Gender Policy. April

2009

This policy objective focuses on gender barriers in

access to health care, promotion of professional

ethics and human rights, improvement of quality of

care, gender inequalities in health service delivery,

HIV/AIDS, gender-based violence, health ﬁnancing

and governance.

Gender Issues Paper (Second Draft). MoH. Ag-

yare-Kwabi

This paper focuses on addressing gender inequal-

ity in health policies and looks at the usual health

services areas such as access, communicable and

non-communicable diseases, reproductive health,

HIV/AIDS, gender-based violence, mental health,

and traditional and cultural gender issues.

The Children’s Act, 1998. Act 560. Gazette noti-

cation 5 February 1999

This act focuses on the rights of the child and paren-

tal duties of care and protection, quasi-judicial and

judicial child adjudication (child panels and family tri-

bunals), parenting, custody, access and maintenance,

foster care and adoption, employment of children,

institutionalized care and miscellaneous matters.

GHANA

MDG ACCELERATION FRAMEWORK

AND COUNTRY ACTION PLAN

MATERNAL HEALTH

July 2011

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