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Background: The United Nations 2030 Sustainable Development Goals have reaffirmed the international community’s commitment to maternal, newborn, and child health, with further investments in achieving quality essential service coverage and financial protection for all. Objective: Using a modified version of the 1978 Tanahashi model as an analytical framework for measuring and assessing health service coverage, this paper aims to examine the system of care at the community level in Ghana’s Volta Region to highlight the continued reforms needed to achieve Universal Health Coverage. Methods: The Tanahashi model evaluates health system coverage through five key measures that reflect different stages along the service provision continuum: availability of services; accessibility; initial contact with the health system; continued utilization; and quality coverage. Data from cross-sectional household and health facility surveys were used in this study. Immunization and antenatal care services were selected as tracer interventions to serve as proxies to assess systems bottlenecks. Results: Financial access and quality coverage were identified as the biggest bottlenecks for both tracer indicators. Financial accessibility, measured by enrollment in Ghana’s National Health Insurance Scheme was poor with 16.94% presenting valid membership cards. Childhood immunization was high but dropped modestly from 93.8% at initial contact to 76.7% quality coverage. For antenatal care, estimates ranged from 65.9% at initial visit to 25.1% quality coverage. Conclusion: Results highlight the difficulty in achieving high levels of quality service coverage and the large variations that exist within services provided at the primary care level. While vertical investments have been prioritized to benefit specific health services, a comprehensive systems approach to primary health care needs to be further strengthened to reach Ghana’s Universal Health Coverage objectives.
While the CHPS+ project is implemented in both the Northern and Volta regions of Ghana, this paper focuses on data from the Volta Region (VR) (now the Oti & Volta Regions). In 2010, VR had a census-enumerated population of 2.1 million, 38% of which was under the age of 15 [15]. The majority (71%) of the population is Christian. The estimated under-five mortality rate is 61 per 1000 live births, although mortality risks are known to vary by district [16]. The Volta Region is one of the poorer performing regions in key health indicators such as immunization coverage [17]. The Tanahashi model, first developed in a seminal paper in 1978, was modified by UNICEF, the World Health Organization, and the World Bank in 2002 for use in the Marginal Budgeting for Bottlenecks tool to estimate the potential impact, resource needs, costs, and budgeting requirements to strengthen national health systems [14]. This adaptation, applied in analyses in more than 50 countries, is a rare framework that moves attention beyond access to health services and brings quality to the forefront, thus highlighting the effectiveness of health systems interventions and potential opportunities to optimize it [18]. This paper applies a modified version of the 1978 Tanahashi model to evaluate health system coverage at the community level through its five key measures (Table 1) that reflect different stages along the service provision continuum [19,20]. These five stages portray the complex interaction between the health system and the population in ways that can highlight gaps in service delivery [21,22]. A particularly useful element of this approach is its capability to distinguish between potential and actual coverage, highlighting gaps between available supply and demand or utilization. Tanahashi model coverage determinants Adapted from Henriksson et al. [22]. This analysis will utilize CHPS+ cross-sectional baseline evaluation data to assess health system strength [14,19]. Given the challenge in accessing quality data for a comprehensive picture of the primary health-care system at the community level, ‘tracer interventions’ will allow for the most relevant and local data to represent the overall system [14]. For this analysis, immunization and antenatal care data, which comprise essential components of maternal and child health and foundational elements of the CHPS initiative, will be used as tracer interventions to represent the Volta Regional Health System’s capacity to deliver essential primary health-care services [23]. We further assess sub-national service delivery by incorporating data on financial access to services in the model via individuals’ enrollment in Ghana’s National Health Insurance Scheme. The five distinct stages of the Tanahashi model (Figure 1) lend themselves to a bottom-up stepwise assessment of health services. In order to understand shortcomings in potential coverage on the supply side (availability and accessibility) and those that affect actual coverage on the demand side (initial contact, continued utilization, and quality coverage), we examine the differences between each level. Modified Tanahashi model The CHPS+ project baseline household survey was conducted in seven of the 25 districts of the VR (Central Tongu, Northern Tongu, Akatsi North, Afadzato South, Nkwanta North, Krachi East, and Krachi Nchumuru) over the April to October 2017 period. Sampling was powered to detect a 15% reduction in under-five mortality at the end of the project, with 80% power at 5% level of significance in each study region, and to draw a representative sample of women of reproductive age (15–49 years) in the CHPS+ project catchment area, collecting information on both the health of women and of their children. The survey used a two-stage stratified cluster sampling approach: the first-stage sampled enumeration areas (EAs), and the second-stage sampled households. EAs were stratified by type of location (rural or urban) and by the size of the EA (measured by the estimated number of households in the EA). EAs were also stratified by size into three groups (small, medium, or large), and subsequently sampled from each stratum using probability proportional to population size. Immunization and antenatal care services were selected as tracer interventions to serve as proxies to assess systems bottlenecks in the study region. The dataset for both services was limited to the analysis of women and their living children aged 12 to 23 months at the time of the survey. To reduce maternal respondent recall bias, data for immunization were restricted to the interviewer’s visual assessment of each child’s immunization card. A total of 11,201 women were interviewed in the Volta Region, 1515 of which had living children aged 12–23 months. Table 2 presents the socio-demographic characteristics of the women and their children included in the analysis. Characteristics of women and their children of 12–23 months *Our data set included information on 1541 children 12–23 months of age (including 28 pairs of twins) belonging to 1515 individual women. The CHPS+ health facility assessment was conducted in July 2018 and collected information on all facilities delivering health services in the 7 CHPS+ survey districts of the VR. The survey included CHPS zones with and without functioning service posts, commonly known as ‘CHPS compounds’, Sub-district Health Centers, private clinics, and District Hospitals. For this analysis, we are limiting data to Ghana Health Service designated CHPS service catchment areas that are either equipped with or lacking functioning compounds and to government health centers (HC) (Table 3). Where services are operational, they function as the most peripheral point of provision of primary health-care services at the community level, especially in remote locations. We furthermore include the primary health-care personnel that should always be available at both CHPS zones and health centers; these include Community Health Officers (CHOs) or Community Health Nurses (CHNs), and Enrolled Nurses (EN). Number and facility type in the Volta Region The health facility survey assessed facility readiness by interviewing a health worker present at the time of interview. This provided information regarding human resources and staffing, routine care, services provided at the facility, and availability of equipment and commodities. The above data sources provide an overview of the community health system in our study region. We use indicators from these CHPS+ data sources to evaluate the five stages of the modified Tanahashi model as per Table 4 below: Measures for immunization and ANC as indicators of health system strength Data were analyzed using Stata 13; the construction of the Tanahashi model graphical representation was done in Microsoft Excel.
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