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

Sexual and Reproductive Health Matters, Volume 28, No. 2, Year 2020

Interpretation

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.

AI Digest

Study Justification:

– Expanding access to sexual and reproductive health (SRH) services is a key target of the Sustainable Development Goals.
– The integration of SRH services within Universal Health Coverage (UHC) initiatives is crucial for achieving SRH targets.
– This study examines the challenges and facilitators to the provision of three SRH services (maternal health, gender-based violence, and safe abortion/post-abortion care) in Ghana.

Highlights:

– Challenges identified include inadequate funding, non-inclusion of certain SRH services in the health benefits package, hidden charges for maternal services, poor supervision, maldistribution of logistics and health personnel, fragmentation of support services for GBV victims, and socio-cultural and religious beliefs affecting service delivery.
– Facilitators for effective SRH service delivery include stakeholder collaboration and support, a health system structure that supports continuum of care, availability of data for monitoring progress, and an effective process for sharing lessons and accountability through review meetings.
– The study proposes the development of a national master plan for SRHR integration within UHC initiatives in Ghana.

Recommendations:

– Address the financial, logistical, and health worker shortages and maldistribution to expand population coverage, service coverage, and financial risk protection in accessing essential SRH services.
– Develop a national master plan for SRHR integration within UHC initiatives in Ghana.

Key Role Players:

– Government agencies (e.g., Ghana Health Service, Ministry of Finance)
– Non-governmental organizations (NGOs)
– Civil society organizations (CSOs)
– Multilateral organizations (e.g., Planned Parenthood Association of Ghana, Marie Stopes International, UNFPA, UNICEF)

Cost Items for Planning Recommendations:

– Funding for SRH services
– Logistics and supplies
– Health worker recruitment and training
– Support for stakeholder collaboration and review meetings

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is based on a qualitative research study that triangulates information from document review and in-depth interviews. The study obtained ethical clearance and used a purposive sampling method to select participants. The data was collected through key informant interviews and desk review. The findings are presented based on facilitators and challenges to the effective provision of sexual and reproductive health and rights services in Ghana. The evidence is supported by the use of a conceptual framework and ethical considerations. To improve the strength of the evidence, the study could have included a larger sample size and employed a quantitative research design to complement the qualitative findings.

Abstract

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.

Materials

N/A

Innovations

The publication titled “Challenges and facilitators to the provision of sexual, reproductive health and rights services in Ghana” explores the barriers and opportunities for improving access to sexual and reproductive health (SRH) services in Ghana. The study identifies challenges such as inadequate funding, non-inclusion of certain SRH services in the health benefits package, hidden charges for maternal services, poor supervision, maldistribution of logistics and health personnel, fragmentation of support services for gender-based violence (GBV) victims, and socio-cultural and religious beliefs affecting service delivery and utilization.

To address these challenges and improve access to maternal health, the publication recommends the development of a national master plan for the integration of SRH services within Universal Health Coverage (UHC) initiatives in Ghana. This master plan should focus on key areas such as financial sustainability, strengthening the health system, collaboration and coordination, and data-driven decision making.

The master plan should allocate adequate funding for maternal health services, including family planning and abortion/post-abortion care, and ensure that these services are included in the health benefits package. It should also address the shortage and maldistribution of logistics and health personnel by improving recruitment, training, and retention strategies. Enhancing supervision and support systems to ensure quality service delivery is crucial.

Additionally, fostering stakeholder collaboration and support to ensure a continuum of care for SRH services is important. Establishing a structured process for sharing lessons and accountability through frequent review meetings can help improve service delivery. Improving data collection and monitoring systems is also recommended to track progress, set priorities, and inform policy and programmatic decisions related to SRH services.

By implementing this national master plan, Ghana can make significant strides in expanding population coverage, service coverage, and financial risk protection in accessing essential maternal health services.

AI Innovations Description

Based on the information provided, here is a recommendation that can be used to develop an innovation to improve access to maternal health:

Develop a national master plan for the integration of sexual and reproductive health and rights (SRHR) services within Universal Health Coverage (UHC) initiatives in Ghana. This master plan should address the challenges identified in the study, such as inadequate funding, non-inclusion of certain SRHR services in the health benefits package, hidden charges for maternal services, poor supervision, maldistribution of logistics and health personnel, fragmentation of support services for gender-based violence (GBV) victims, and socio-cultural and religious beliefs affecting service delivery and utilization.

The master plan should focus on the following key areas:

1. Financial sustainability: Allocate adequate funding for maternal health services, including family planning and abortion/post-abortion care. Ensure that these services are included in the health benefits package and eliminate hidden charges for maternal services.

2. Strengthening the health system: Address the shortage and maldistribution of logistics and health personnel by improving recruitment, training, and retention strategies. Enhance supervision and support systems to ensure quality service delivery.

3. Collaboration and coordination: Foster stakeholder collaboration and support to ensure a continuum of care for SRHR services. Establish a structured process for sharing lessons and accountability through frequent review meetings.

4. Data-driven decision making: Improve data collection and monitoring systems to track progress, set priorities, and inform policy and programmatic decisions related to SRHR services.

By implementing this national master plan, Ghana can make significant strides in expanding population coverage, service coverage, and financial risk protection in accessing essential maternal health services.

AI Innovations Methodology

The methodology described in the abstract involves a qualitative research approach to examine the challenges and facilitators to the provision of sexual and reproductive health and rights (SRHR) services in Ghana. The study uses a combination of document review and in-depth qualitative stakeholder interviews to gather data.

The document review involves searching and retrieving relevant documents such as research reports, peer-reviewed articles, and policy and legal documents related to SRHR in Ghana. Annual reports and websites of key institutions in Ghana’s health sector are also included in the review. The review applies relevant keywords and Boolean operators to ensure comprehensive coverage of relevant information.

For the in-depth interviews, purposive sampling is used to select individuals who have in-depth knowledge of SRHR issues in Ghana. Key informants are selected from government, non-governmental organizations (NGOs), civil society organizations (CSOs), and multilateral organizations involved in SRHR decision-making, program implementation, and advocacy. The interviews are conducted with twelve respondents who have experience in SRHR programs and policies in Ghana.

To ensure data quality, experienced researchers with qualitative research skills are deployed after undergoing a three-day intensive training. The interview guide is pre-tested and revised based on feedback. The interviews are tape-recorded and transcribed verbatim. The transcripts are validated for accuracy, organized, and coded thematically.

The results from the stakeholder interviews are triangulated with findings from the document review to improve the validity of the results. Convergent issues from both data sources are identified as facilitators or challenges to the effective provision of SRHR services in Ghana. The analysis considers a conceptual framework that focuses on “structure” and “process” issues.

Ethical clearance is obtained from the Ghana Health Service Ethical Review Committee and the World Health Organization’s Ethics Review Committee. Written informed consent is obtained from all participants involved in the in-depth interviews. Data analysis and presentation ensure the anonymity and confidentiality of study participants.

Overall, this methodology provides a comprehensive approach to understanding the challenges and facilitators to the provision of SRHR services in Ghana and can inform the development of a national master plan for integrating SRHR within Universal Health Coverage initiatives.

Author

Dima Health

Statistics:

Citations: 8

Identifiers:

DOI: 10.1080/26410397.2020.1846247

Research Areas:

Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Noncommunicable Diseases, Quality of Care, Sexual and Reproductive Health

Study Countries:

Ghana

Study Design:

Cross Sectional Study, Grounded Theory

Study Approach:

Mixed-methods, Qualitative

Participants Gender:

Male & Female