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How a child mortality intervention is bridging the poverty gap in Ghana

The impact of this evidence-based policy is rippling across Africa

Vaccinations in Africa
Vaccinations in Africa © istock.com/Sean_Warren

Each month the Elsevier Atlas Award recognizes research that could significantly impact people's lives around the world.

Does the provision of community health services offset the effects of poverty and low maternal educational attainment on childhood mortality? An analysis of the equity effect of the Navrongo experiment in Northern Ghana

Ayaga A. Bawah, James F. Phillips, Patrick O. Asuming, Elizabeth F. Jackson, Paul Walega, Edmund W. Kanmiki, Mallory C. Sheff, Abraham Oduro
SSM - Population Health, Volume 7, April 2019, 100335

For every 1,000 babies born in Ghana, nearly 50 will die by the age of five; in 1990, when Dr. Ayaga Bawah started investigating an intervention to improve survival in the poorest communities, the child mortality rate was more than double this. He set out to research an intervention that involved taking healthcare services into rural communities. Almost three decades later, he has shown in a study in SSM - Population Health that the intervention doesn’t just reduce child mortality, it’s also helping close the poverty gap by offsetting the impact on child mortality of mothers being uneducated.

Dr. Bawah, who is Senior Lecturer at the Regional Institute for Population Studies at the University of Ghana, said:

“Women who are educated tend to be exposed to better health facilities by virtue of the fact that when they are educated, they are capable of accessing information that will help them make the right choices to ensure that their children live. We wanted to see the extent to which Ghana’s intervention could serve as not just a way to reduce child mortality, but to bridge the equity gap between the rich and the poor by reducing the power of education in this context.”

The new findings are shaping health policy across the country and beyond, and the paper, by a team from the University of Ghana, Columbia University and the Ghana Health Service, has won the Atlas Award for its impact.

Taking health services to the community

Back in the 1990s, healthcare services in Ghana were located in facilities in towns and cities, where doctors and nurses would wait for people to turn up. The poor people living in rural areas could not afford transport to the facilities, so they didn’t have access to healthcare – this included the uneducated mothers at high risk of child mortality.

Dr. Bawah and his colleagues tested an intervention in which healthcare services were provided within the communities – on the doorsteps of the people who couldn’t usually afford to access them. When they showed how effective the intervention was, that it actually reduced child mortality, the government was excited and quickly established it as policy across the country. Dr. Bawah explained:

“Once we were finding positive results that supported our hypothesis, it was not difficult to communicate this back to policy makers. And once they understood what was going on, they just ran with it.”

But when scaling up the intervention across the country, some inconsistencies crept in and the effectiveness was being questioned; some evidence was needed to determine exactly what approach works best.

In the new study, Dr. Bawah and his colleagues assessed the long-term impact of the community healthcare intervention on the mortality of 94,599 children under the age of five, between 1995 and 2010. They looked at the impact of the intervention, following four strategies: training volunteers to promote health in communities; placing qualified nurses in communities; combining volunteers and nurses; and a control situation where there was no community intervention.

They found that when nurses are available in the community, the increased risk of child mortality for uneducated, poor families is offset – in other words, all families had the same risk of child mortality, regardless of their economic status or education level. They also showed that when only volunteers are available, the benefit was limited to relatively advantaged households.

The results give a clear signal that nurses working in the community have a significant impact on reducing child mortality and closing the poverty gap. Dr. Bawah said:

“Given the compelling evidence, we teamed up with the government of Ghana and we are scaling the model up to the rest of the country. We've got funding to start with a few districts and make sure that they get the concept right, and then those will become ‘learning localities’ where other districts can learn, causing a cascading effect.”

By putting this system in place, Dr. Bawah hopes to make as wide an impact as possible, reaching not only Ghana but countries throughout the African continent. He added:

“We thought that we were doing research that would impact on lives, and we were happy to have demonstrated that empirically. I'm very excited that this work is impacting lives, and I thank Elsevier for finding this work worthy and for making the efforts to make sure that it gets a much wider readership.”

Dr. Ayaga Bawah and Elsevier’s Ylann Schlemm at the Atlas Award Ceremony
Dr. Ayaga Bawah and Elsevier’s Ylann Schlemm at the Atlas Award Ceremony
Credit: Paul Koutanyi

A conversation with Dr. Ayaga Bawah

A child mortality intervention put into policy two decades ago helped reduce infant deaths in Ghana, but according to a study by researchers at the University of Ghana, it may even help close the wealth gap when it comes to healthcare access. Here author Dr. Ayaga Bawah talks about the intervention, the challenges and what’s next.
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What is the situation today when it comes to child mortality in Ghana?

Child mortality is still pretty high; there has been considerable decline over the last couple of years, but if you compare it to with some other parts of the world, you realize it is still pretty high. As of the last demographic and health survey, it is around 50 deaths per 1,000 live births.

In your paper, you point to previous research showing a link between poverty education and child mortality. Can you explain that?

Education is one of the powerful factors that influence behavior. For instance, women who are educated tend to be exposed to better health facilities by virtue of the fact that when they are educated, they are capable of accessing information that will help them make the right choices to ensure that their children live. Women who are educated tend to have higher incomes than those who are not educated, so they are in a position to buy better health. And this has been shown in almost every setting, that education is a powerful predictor of childhood mortality.

What’s the background to this work?

In the 1990s, the government of Ghana was very concerned about the high levels of child mortality in northern Ghana and was interested in taking health services to rural communities to make them much more available to people who would otherwise not have access to them. They deployed an intervention called the Community-based Health Planning and Services (CHPS) project, delivering a package of services to rural communities. I was part of a study to see whether these services would have an impact on improving child survival. At the end of the study we were able to show that child mortality was actually reduced.

What do you look at in your Atlas Award-winning study?

We wanted to see the extent to which this intervention could also serve as not just a way to reduce child mortality, but to bridge the equity gap between the rich and the poor. The basic argument is that the poor may not have access to services if they’re not close to them, as they can’t afford transport to the health centers. If you take those services right to the doorstep of the community, that access barrier then becomes a bridge – both the poor and the not so poor would equally have access to those services because they are available within the same communities. We set out to test that empirically, to see whether this indeed would be the case.

What are the implications? Are you suggesting any changes to health care approaches?

When we started this work, the health delivery system in Ghana had static facilities like hospitals and clinics and health personnel who were seated in those facilities, waiting for people to come and access the services. We suggested if you take the services to the communities, this is going to be a game changer. And indeed when we showed that this was the case, the government of Ghana decided that this was the way to go and immediately announced a policy change, taking services from those static facilities and to the doorsteps of the communities. This has not just influenced policy in Ghana; since we published our findings, several other countries in the region – including Sierra Leone and Nigeria – have visited Ghana to learn from this model.

How did you make that happen? Did you actively go out with your results and take them to policy makers?

Right from the beginning we engaged the Ghana Health Service to let them know that this is what was going on. We also engaged the communities, elders and leaders to make sure that they were aware of the work we were doing. When the results were coming out, we called for a policy dialogue, a conference in the capital city of Accra, to disseminate the results. The Minister of Health at the time came to this conference and when we provided this compelling evidence the minister decided to run with it.

What's it like working on this and being so involved in policy?

My philosophy has always been that undertaking research that does not change lives should not be encouraged, because it's very costly to undertake research – you shouldn't just do research that ends up on the shelves, it should impact lives. Although I'm a demographer, most of my research has focused on health: how do you improve health systems in ways that can have an impact on survival? I enjoy doing policy research, even now that I'm at the university, and I still collaborate with the Ghana Health Service. It's quite an interesting way of working, ensuring that your work is impacting on the greater community.

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About SSM - Population Health

SSM - Population Health is an online only, open access, peer-reviewed journal covering all areas relating social science research to population health. It is the sister journal of Social Science & Medicine and takes a broad approach to the field, especially welcoming interdisciplinary papers from across the social sciences and allied areas.

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