Challenges and facilitators to the provision of sexual, reproductive health and rights services in Ghana

Expanding access to sexual and reproductive health (SRH) services is one of the key targets of the Sustainable Development Goals. The extent to which sexual and reproductive health and rights (SRHR) targets will be achieved largely depends on how well they are integrated within Universal Health Coverage (UHC) initiatives. This paper examines challenges and facilitators to the effective provision of three SRHR services (maternal health, gender-based violence (GBV) and safe abortion/post-abortion care) in Ghana. The analysis triangulates evidence from document review with in-depth qualitative stakeholder interviews and adopts the Donabedian framework in evaluating provision of these services. Critical among the challenges identified are inadequate funding, non-inclusion of some SRHR services including family planning and abortion/post-abortion services within the health benefits package and hidden charges for maternal services. Other issues are poor supervision, maldistribution of logistics and health personnel, fragmentation of support services for GBV victims across agencies, and socio-cultural and religious beliefs and practices affecting service delivery and utilisation. Facilitators that hold promise for effective SRH service delivery include stakeholder collaboration and support, health system structure that supports continuum of care, availability of data for monitoring progress and setting priorities, and an effective process for sharing lessons and accountability through frequent review meetings. We propose the development of a national master plan for SRHR integration within UHC initiatives in the country. Addressing the financial, logistical and health worker shortages and maldistribution will go a long way to propel Ghana’s efforts to expand population coverage, service coverage and financial risk protection in accessing essential SRH services.

Ghana has a population of about 30 million people. Administratively, the country is sub-divided into 16 regions, and 216 districts.18,19 Ghana’s female population is slightly higher than the male (50.8% vs. 49.2%) and about 56.1% of the population live in urban settlements.19 Life expectancy is 63 years while total fertility currently is 4.0.15,20 Maternal and child mortality are relatively high. The main causes of maternal deaths in Ghana are obstetric haemorrhage, hypertensive disorders, abortion-related complications and infectious diseases.15,21 Under-five mortality is higher in rural settings (56 deaths per 1000 live births) compared to urban settings (48 deaths per 1000 live births). Childhood mortality is also disproportionately distributed among the regions of the country with the Greater Accra region having the lowest rate of 42 deaths per 1000 live births while the Upper West region (Ghana’s poorest region) has the highest under-five mortality rate of 78 deaths per 1000 live births.15 Antenatal care (ANC), child health care (vaccinations etc.) and nutrition services are largely supported with donor funds and are free, but the concern is whether the gains could be sustained as donors support dwindles.22 This is mainly a qualitative research study triangulating information from document review and in-depth interviews. Data was collected through in-depth stakeholder interviews and desk review. The desk review applied the use of relevant key words and Boolean operators to search and retrieve relevant documents including research reports, peer reviewed articles, and policy and legal documents related to SRHR in Ghana. In addition, annual reports and websites of key institutions in Ghana’s health sector were included in the review (Supplementary Tables 1 and 2 provide more information on the keywords and websites that were searched and a list of documents reviewed). Since qualitative research is not aimed at achieving randomness but at gaining a deeper understanding of the issues,23 purposive sampling was employed to select individuals to participate in the in-depth interviews. Key informants were purposively selected from the level of policy decision-making and programme implementation from government, non-governmental organisations (NGOs) and civil society organisations (CSOs), including the Ghana Health Service (GHS), Ministry of Finance, Population Council, and multilateral organisations including Planned Parenthood Association of Ghana, Marie Stopes International, UNFPA and UNICEF. Primary data was collected mainly through key informant interviews conducted between January and February 2020 with persons who have in-depth knowledge of SRHR issues in Ghana. Twelve respondents who are involved or have been involved in either decision-making or implementation of SRHR programmes or in advocacy for the implementation of SRHR policies or programmes in Ghana were interviewed. To select the participants for the in-depth interviews, letters were sent to the targeted institutions and scheduled officers with deeper insights into the issues were selected. In some instances, institutions requested the interview guide to enable them to understand the issues for discussion and to select the most suitable person for interview. To ensure data quality, experienced researchers with the requisite skills in qualitative research were deployed after undergoing a three-day intensive training. The training allowed the research team to thoroughly review the interview guide and to be conversant with the questions and develop a common understanding of questions and probes before going to the field. The interview guide was first pre-tested with lower-level healthcare managers to ascertain the validity of the questions, after which it was appropriately revised and made ready for data collection. The interviews were tape-recorded. Figure 2 depicts the categories of stakeholders who were interviewed. Individual interviews (IDIs) conducted per stakeholder category The tape-recorded interviews were transcribed verbatim by experienced researchers. Quality of transcripts was validated by swapping tapes among transcribers and listening to check for accuracy of content. The validated transcripts were then organised and coded thematically. Results from the stakeholder interviews were triangulated with findings emanating from the desk review to improve validity of results. Our triangulation involved a point-by-point comparison of results with the aim of identifying convergent issues from both data sources that serve as either facilitators or challenges to the effective provision of SRHR services in Ghana. This approach to triangulation is a within-method data source triangulation since both in-depth interviews and desk review are qualitative methods but different approaches to data collection and processing.24–26 Analysis took into consideration our conceptual framework thus: results are presented based on the facilitators and challenges with regards to “structure” and “process” issues. The study obtained ethical clearance from the Ghana Health Service Ethical Review Committee (GHS –ERC024/10/19) and the World Health Organization’s Ethics Review Committee (WHO ERC.0003365). Written informed consent was obtained from all participants involved in the in-depth interviews. Data was analysed and presented in a manner to preserve anonymity and confidentiality of study participants.

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• akazili, james
• kanmiki, edmund wedam
• anaseba, dominic
• govender, veloshnee
• danhoundo, georges
• koduah, augustina