Simulating Alternatives to Achieve 35% Reduction in Maternal

Global
Development
Network
Strengthening
Institutions
to Improve
Public Expenditure
Accountability
Simulating Alternatives to
Achieve 35% Reduction in
Maternal Mortality by 2015
Dennis Nchor
and
Jonathan Adabre
Integrated Social Development Centre
(ISODEC, Ghana)
TABLE OF CONTENTS
1. INTRODUCTION AND BACKGROUND ....................................................................................................... 3
Brief Profile of the Five Regions .................................................................................................................... 7
2. LITERATURE REVIEW ................................................................................................................................ 7
3. POLICY ALTERNATIVES ............................................................................................................................ 10
4. METHODOLOGY ...................................................................................................................................... 13
4.1 Data Sources ......................................................................................................................................... 13
4.2 Expected Beneficiaries .......................................................................................................................... 14
4.3 Assumptions .......................................................................................................................................... 14
4.4 Analysis Approach ................................................................................................................................. 15
4.4.1 Relative Benefits ................................................................................................................................ 15
4.4.2 Relative Costs ..................................................................................................................................... 15
4.4.3 Cost-Effectiveness Analysis ................................................................................................................ 17
4.4.4 Sensitivity Analysis ............................................................................................................................. 19
4.4. 5 Measuring Equity of Alternatives...................................................................................................... 19
4.4.6 Paying for the Alternatives ................................................................................................................ 19
APPENDIX .................................................................................................................................................... 20
REFERENCES ................................................................................................................................................ 21
1. INTRODUCTION AND BACKGROUND
According to the World Health Organization (WHO), "a maternal death is the death of a woman
while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and
site of the pregnancy, from any cause related to or aggravated by the pregnancy or its
management but not from accidental or incidental causes.1 Statistics from the United Nations
indicate that each year, more than 350,000 women in the developing world, between the ages
of 15-49 die of pregnancy and child-birth related complications and that Asia and Sub-Saharan
Africa accounted for 87 percent (313,000) of global maternal deaths. According to the WHO, a
woman's lifetime risk of dying from pregnancy is 1 in 3700 in North America compared to 1 in
16 in Africa. In Ghana, the risk is 1 in 35 (WHO, n.d.).
There are varied reasons as to why maternal mortality is so unacceptably high in Africa and for
that matter in Ghana. Elizabeth Ransom (2000) in ‘Making Pregnancy Safer’ noted that the risk
of dying from pregnancy-related causes is highest in Africa because African women have more
children than women on other continents and that the risks become greater with each
pregnancy. The Ghana Maternal Health Survey, 2008 identified hemorrhage as the largest
single cause of maternal deaths (24 percent). Abortion, hypertensive disorders, sepsis,
miscarriage and obstructed labor were also cited as causes of maternal death.
Figure I: Causes of Maternal deaths2
*Other direct causes including, for example, ectopic pregnancy, embolism, anaesthesia-related. ** Indirect causes
including, for example, anaemia, malaria, heart disease.
Kojo Sena (2003) provides both a medical explanatory and socio-cultural context analysis of
why maternal mortality is so high in Ghana and highlights how medical conditions and sociocultural factors intertwine to produce maternal morbidity and mortality. According to him
delays in accessing emergency gynecological and obstetrics services caused by both medical
and socio-cultural conditions is the major causal factor of high maternal deaths in Ghana. He
identifies four types of delays — delay in recognition of the dangers associated with a
pregnancy, delay in decision to take appropriate action, delay in arriving at a health facility and
delay within a health facility — as causing needless maternal deaths.
1
Maternal Mortality in Central Asia, Central Asia Health Review (CAHR), 2 June, 2008
“Coverage of Maternal Care: A Listing of Available Information, Fourth Edition.” World Health Organization,
Geneva 1997.
2
Table 1: Estimated average time interval from onset of complication to death
Complication
Hours
Days
Hemorrhage (post-partum)
Hemorrhage (ante-partum)
Ruptured uterus
Eclampsia
Obstructed labor
Infection
2
12
1
2
3
6
Source: Maine et al. (1987)
Whatever the cause, the death of a woman due to pregnancy-related complications is indeed
tragic and unacceptable in all contemporary societies. In Ghanaian societies this tragic event is
sometimes followed by elaborate ritual purification of the whole society (Kodjo Senah 2003). In
the contemporary world, maternal mortality is perceived as a violation of the rights of women
and its rate as a critical pointer to the level of development of a country (Ibid). Ghana is one of
the many developing countries to ratify international conventions; the International Conference
on Population and Development (ICPD); the Maputo Plan of Action; the Abuja target of
allocating at least 15 percent of the national budget to health and the Campaign to Accelerate
Reduction of Maternal Mortality in Africa (CARMMA), all aimed at improving reproductive and
maternal health in line with the country’s avowed goal of protecting the rights of women.
Ghana has also committed itself to achieving the United Nations’ Millennium Development
Goals (MDGs) on maternal health, infant mortality and HIV/AIDS, tuberculosis, malaria and
other diseases — most often referred to as the ‘Health MDGs’ — by putting in place various
reproductive health policies, including the adolescent reproductive health policy, safe
motherhood protocols, reproductive health strategy plan and child health policy as well as
declaring maternal mortality as a national emergency in 2008, all to improve maternal and child
health. It has also signed many legislative and human rights instruments such as the Convention
on the Elimination of all forms of Discrimination (CEDAW) and the International Covenant on
Economic, Social and Cultural Rights (ICESCR) among others that promote the welfare of
women, particularly the MDGs (5).
In spite of all these, reduction in maternal and child mortality remains unattained. The unmet
need for family planning remains at a high 35 percent, skilled delivery at a low 45.6 percent;
acute shortage of midwives persists while health staff remains inequitably distributed, with 43
percent of doctors in Greater Accra Region and 4 percent for three northern regions (MOH
review report, 2010).
According to the World Bank Global Monitoring Report (2012), corroborated by the CIA
Factsheet (2012), and UNICEF (2012), Ghana’s maternal mortality ratio (MMR) stood at
350/100,000 live births as in 2008, falling from a ratio of 540/100,000 in 2000 to 451/100,000 in
2007 and 350/100,000 in 2008. The reduction, 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 Greater Accra (by 87.6 per 100,000).
Source: Ghana Census 2010
With the current trend of progress, Ghana is unlikely to achieve the target of MDG 5 by 2015.
Indeed, Ghana’s human rights body, the Commission on Human Rights and Administrative
Justice (CHRAJ), in its 2011 report on the ‘State of Human Rights In Ghana’ indicated that if the
current trend continued, maternal mortality would reduce approximately to 340 per 100,000
live births by the set date of 2015.
This has prompted calls by various stakeholders including the WHO3 and the UNDP for the
implementation of simple community-based interventions that will aid the defaulting countries,
3
WHO: Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child
Health (RMNCH), December 2011.
like Ghana, attain the MDG 5 target by 2015. Recent experiences in Ghana demonstrate that
success is possible and that evidence-based effective interventions can be identified for
realizing the MDGs. This development has led to the current MDG Acceleration Framework
(MAF) which is to capitalize on the existing commitment and capture the evidence available to
put forward concrete and realistic proposals to scale up the achievement of the MDGs. 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. Hence the main goal of the MAF is to redouble
efforts to overcome bottlenecks in implementing the 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 healthcare 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 intervention areas identified
are: improving family planning, skilled delivery and emergency obstetrics, and newborn care.4
It is in this context that the Integrated Social Development Centre (ISODEC) is simulating two
policy scenarios: (1) Training and deploying Skilled Birth Attendants (SBAs) at health centers in
the five worst affected regions of Ghana by the year 2015 and (2) Training and deploying SBAs
at district hospitals in the five worst affected regions of Ghana by the same year to find out if
one or both will help Ghana achieve, or be close to achieving, the MDG 5 target of a maternal
mortality rate of 185 per 100,000 live births by 2015.
The simulation seeks to answer the following question and to establish certain related aspects
of each policy alternative.




What policy alternative/s would reduce maternal mortality in Ghana by a significant rate
of 35 percent by the year 2015 so as to attain the MDG 5 target or be close to the target
by that date?
The research will also seek to establish the cost associated with each of the policy
alternatives and measure the cost-effectiveness ratio for each policy intervention.
It also seeks to establish the benefit incidence analysis as well as the relative
effectiveness of each policy intervention to measure the benefits, particularly to the
poor
It will seek to establish how the chosen policy option will be financed and draw
conclusions as to the way forward.
For the purpose of achieving direct results from this simulation, and given the data requirement
challenges, this research would focus more on 5 out of 10 regions of Ghana that are deprived
and that have the highest maternal mortality. The five regions include the three northern
regions (Northern, Upper East and Upper West), Volta and Central regions of Ghana.
4
MDG Acceleration Framework and Country Action Plan; July 2011
BRIEF PROFILE OF THE FIVE REGIONS
Maternal deaths have been attributed to a large number of factors but the situation in the
three northern regions is exacerbated due to causes ranging from poverty, inaccessible and
unavailable hospitals, poor road networks, unqualified health personnel, negligence
on the part of the health personnel and other undesirable customary practices, all of which
are contributing factors to the ever increasing rate of maternal deaths.
Studies in Ghana have shown that access issues tend to be more pronounced in areas with a
range of interlocking socio-economic factors. For example, high levels of illiteracy, low levels of
human resource and economic development, low levels of democratic participation, high levels
of infant and child mortality and morbidity, and low levels of general family health, among
others (Ministry of Education, 2002). In Ghana such areas are more likely to be found in the
northern parts.
Source: EMoNC Survey (2010).
2. LITERATURE REVIEW
Simulation has been used unsystematically since the early days of medicine (Amitai Z., et al.
2003). In the 16th century, mannequins (referred to as phantoms) were developed to teach
obstetrical skills and reduce high maternal and infant mortality rates. Today, it is common for
students to administer their first injections on an orange, practice suturing on pieces of cloth,
rehearse medical interviews while role playing, or practice physical examination on simulated
(standardized) patient-actors (Ibid). Though healthcare simulation has lagged behind other
high-hazard professions, such as aviation, nuclear power and military due to a number of
reasons including cost, lack of rigorous proof of effect and change resistance, the scourge of
maternal and neonatal mortality has led to increased simulations around the myriad factors
causing maternal and neonatal deaths, all aimed at arriving at concrete policy options that will
either eliminate maternal deaths or reduce their rate.
According to Kodjo Senah (2003) global attention began to be focused more seriously on
maternal mortality in 1985, when Rosenfield and Maine (1985) published a thought-provoking
article in the Lancet. In the article titled 'Maternal Mortality — a neglected tragedy — where is
the M in MCH?', Rosenfield and Maine alerted the world to the fact that many developing
countries were neglecting this important problem and that the existing programs were unlikely
to reduce the high maternal mortality rates in the developing world. Another significant
contribution to the crusade against maternal mortality was the WHO (1986) publication,
'Maternal Mortality: helping women off the road to death.' All these led to the Safe
Motherhood Conference in Nairobi, Kenya in 1987. Ever since, a series of policy simulations
have been carried out to find policy solutions to the problem.
Employing a multivariate analysis, Lavest A. Thomas (1990) examined the degree to which the
substantial race disparities in post neonatal mortality are a function of race disparities within
the prevalence of poverty. The analysis specifies a race-specific model of post neonatal
mortality. It concludes that racial post neonatal mortality differentials may be addressed by
effective policy that reduces disparities in socio-economic status, implying that poor socioeconomic conditions led to increased rate of maternal and neonatal deaths.
Similarly, Hotchkiss R.D., et al. (2005) examined the role of household out-of-pocket costs and
structural attributes of quality on the use of maternity care in Morocco using empirical data
collected from both households and healthcare facilities. In the study, a nested logic model was
estimated; the coefficient estimates were used to carry out policy simulations of the impact of
changes in the levels of out-of-pocket fees and structural attributes of quality to guide the
policymakers responsible for the design of a pending social insurance program. It was found
that social insurance strategies involving increases in out-of-pocket charges in the form of copayments could be implemented without untoward effects on the appropriate use of maternity
care for non-poor women, but would be contraindicated in the case of poorer and rural
households.
In examining alternative strategies to reduce maternal mortality in India, Goldie S.J., et al.
(2010) used a computer-based model that simulated women through pregnancy and childbirth
to estimate the effect of different strategies (for example, increased family planning or greater
access to obstetric care) on clinical outcomes (pregnancies, live births, or deaths), costs, and
cost-effectiveness (the cost of saving one year of life). It found that an increase in family
planning was the single most effective intervention in reducing pregnancy-related mortality,
capable of averting more than 150,000 maternal deaths and saving more than US$1 billion if
prevailing unmet need for family planning in India could be fulfilled over the next five years. It,
however, found that increased family planning alone could reduce maternal deaths by only 35
percent at the most but that an integrated and a step-wise approach (increased family planning
and safe abortion combined with consecutively increased skilled birth attendants, improved
care before and after birth, reduced home births, and improved emergency obstetric care)
could eventually prevent nearly 80 percent of maternal deaths.
On causal factors such as hemorrhage, Sutherland Tori and Mishai M. David (2009) simulated
the use of Misoprostol as a cost-effective postpartum hemorrhage control intervention and
concluded that iron supplementation may be worthwhile in improving women's health, but
that uncertainty remained as to whether it could prevent mortality after hemorrhage. The
study, however, established that the use of Misoprostol as a postpartum hemorrhage
preventive intervention resulted in a 38 percent decrease in maternal deaths, while prenatal
iron supplementation resulted in a 5 percent decrease.
The role and effectiveness of skilled birth attendants has been largely explored in some
research work. A study in rural Nepal showed that women’s group activities influenced women
to seek prenatal care, childbirth with a skilled birth attendant, and better hygiene, resulting in a
30 percent reduction in neonatal mortality and 80 percent reduction in maternal mortality (D.
Manandhar, et al. 2004).
While SBAs can attend births either in women's homes or in health facilities, their power to
save maternal lives increases dramatically with appropriate back-up (i.e., medical personnel
and equipment), which forms a strong argument for facility-based deliveries. Since maternal
complications are often unpredictable, woman in labor and delivery will remain safest if
attended by an SBA in a well-supplied and functioning health facility. A woman's next safest
option would be to give birth at home attended by an experienced SBA with the necessary
equipment and drugs (Prata et al. 2011).
Bhutta et al. (2010) in their systematic review on human resources for health interventions to
improve maternal health outcomes found that human resource can improve both healthworker performance and maternal health outcomes. They also found that two quasiexperimental, two cross-sectional and eight before-after studies, mostly from Africa and SouthEast Asia, assessing the effects of HR training interventions showed that training the skilled
birth attendants and other healthcare workers improved the basic knowledge and skills (such as
abdominal examinations and safety measures when taking blood samples) of more than 70
percent of staff, and reduced maternal mortality in most locations.
In Ghana, there have not been many studies directed at simulating the effectiveness of the
proposed policy alternatives — the training and deployment of SBAs to all underserved
communities, particularly the district hospitals and health centers — in reducing maternal
mortality. However, there have been studies for the evaluation of a program to train the
traditional birth attendants (TBAs). For instance, Neumann et al. (1974) showed that the
training program for TBAs has a favorable impact on the midwifery care given to women, thus
decreasing maternal and infant mortality. However, a systematic review lends support to early
findings suggesting that trained TBAs, without the support of skilled back-up services do not
reduce the maternal mortality ratio. In Ghana deliveries assisted by TBAs are not regarded
as skilled care at delivery (MDG 5 Review, November Summit, 2008).
Tamunosa et al. (2007) also sought to look at safe motherhood programs in Ghana, Burkina
Faso and Indonesia and came out with the findings: Many funding agencies supposedly
supporting safe motherhood programs in Ghana are actually pursuing a broader reproductive
health agenda. All but two of the initiatives examined had multiple goals, many placing high
importance on the reproductive health agenda. Also, safe motherhood programs in Ghana are
mostly donor-funded, and many of the funders have reproductive, sexual health or family
planning goals. Some donors continue funding outside of the SWAp, which could create an
imbalance in the attention paid to national targets; the program design reflects a focus on the
supply-side activities, maintaining a top-down approach in decision-making and creating an
imbalance of behavior change or community mobilization interventions.
3. POLICY ALTERNATIVES
The goal of the policy simulation exercise is to help identify policy alternatives that will reduce
maternal mortality by 35 percent by the year 2015 so as to enable Ghana to achieve the MDG
2015 target of MMR of 185 per 100,000 live births. The exercise is largely informed by the fact
that most maternal deaths and disabilities could be averted if all births were attended by a
skilled health professional with access to a quality referral facility (FCI 2002). Also, the survey
results indicate that Ghana is unlikely to meet the MDG 5 target by the set date; this in
response to the urgent call for the implementation of innovative approaches to fast-track the
reduction in maternal mortality rates leading up to the achievement of the MDG target.
The proposed policy alternatives are:
i.
The training and deployment of Skilled Birth Attendants (SBAs) at district hospitals in
the deprived regions in Ghana
ii. The training and deployment of Skilled Birth Attendants (SBAs) at health centers in the
deprived regions in Ghana
In reviewing the existing policies and interventions available for attaining the MDG 5 in Ghana,
the MDG Acceleration Framework and Country Action Plan, Ghana (2011) team identified three
key interventions that emerged as having great impact on maternal health, namely, family
planning (FP); skilled delivery services (SD); and emergency obstetrics and neonatal care
(EmONC).
Going by the review, it is our considered opinion that the target of 35 percent reduction in
maternal mortality by the year 2015 is possible and achievable given the availability of such
evidence within and outside the country.
Table 1: Trends in skilled delivery by region (2006-2010)
Supervised Delivery 2007
2008
2009
Ashanti Region
26.7
35.0
42.4
Brong Ahafo
34.5
49.8
53.7
Central Region
22.3
56.3
52.5
Eastern Region
43.1
48.0
52.1
Greater Accra
43.1
50.2
47.9
Northern
27.7
26.0
36.1
Upper East
43.5
40.4
52.6
Upper West
32.9
40.6
36.7
Volta
33.3
37.5
39.4
Western
17.6
39.1
42.6
National
32.1
42.2
45.6
2010
53.4
54.0
51.6
48.2
54.4
36.8
59.7
46.5
36.9
49.6
49.5
Source: Ghana Health Service; 2010 Annual Report
One of the objectives of the Millennium Development Goal accelerated framework is to achieve
80 percent skilled delivery coverage by the year 2015.
Skilled delivery rate improved nationally from 45.6 percent in 2009 to 49.5 percent in 2010.
However, there are inter-regional variations: Upper East, Western, Northern, Ashanti and Brong
Ahafo region have all shown consistent increase in skilled delivery from the year 2008. Greater
Accra recovered from the drop in 2009 and increased coverage to 54.4 percent; this may be a
reflection of the improvement in data collection from the private sector. There has been a
reduction in coverage in the Volta and Eastern region. Skilled delivery coverage, which is
delivery carried out by a trained health worker is dependent on the distribution of the skilled
staff. The Volta region has seen a worsening in the midwife-to-population ratio during the year
2010. Also most of the nurses here are old, so they are not practicing.
A skilled birth attendant defined by WHO as “an accredited health professional — such as a
midwife, doctor or nurse — who has been educated and trained to proficiency in the skills
needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate
postnatal period, and in the identification, management and referral of complications in
women and newborns. Traditional birth attendants, trained or not, are excluded from the
category of skilled attendant at delivery. In developed countries and in many urban areas in
developing countries, skilled care at delivery is usually provided in a health facility. However,
birth can take place in a range of appropriate places, from home to tertiary referral center,
depending on availability and need, and WHO does not recommend any particular setting.
Home delivery may be appropriate for a normal delivery, provided that the person attending
the delivery is suitably trained and equipped and that referral to a higher level of care is an
option.”
In Ghana, professional assistance at birth for women in urban areas, it has been found, is twice
as likely than for women in the rural areas (MOH 2008). Achieving skilled attendance at delivery
for all has been a huge challenge. However, the proportion of births attended by a Skilled Birth
Attendant (SBA) is a key indicator of the level of progress towards MDG 5.
In relation to the decentralization process in the 10 regions and 138 districts and sub-districts,
the organizational structure of the national healthcare system in Ghana includes a hospital at
the regional level. Below the regional level, rural healthcare is divided into three levels: district
hospitals, sub-district health centers or polyclinics, and CHPS/Community-level facilities. At the
community level, a small health point is located in one village, covering several (5–10) villages.
In the best-case scenario, a community health officer is assisted by a professional nurse, an
auxiliary nurse, midwives, and one or two community health volunteers (USAID, June 2006).
Evidence suggests that the best strategy for reduction in maternal mortality is likely to be one
in which women routinely choose to deliver at a health center, with midwives as the main
providers (basic essential obstetric care). The treatment component would include all the basic
emergency obstetric functions, apart from blood transfusions or surgery, which would be
available at the referral level as comprehensive emergency obstetric care. Ensuring that such
services are within women’s easy reach at the time of delivery would also ensure their being
close enough to receive timely help should the need for emergency care arise during the
antenatal or postpartum period (November Summit 2008: Progress towards Millennium
Development Goal 5 in Ghana).
It has been calculated that, with an assumed load of 150 deliveries annually per midwife, plus
associated prenatal and postnatal care, around 400,000 midwives will have to be trained
(Walraven & Weeks 1999). These estimates can be expected to rise as increasing numbers of
young women enter the reproductive age group.
The training of the SBAs becomes necessary for the newborn’s health. During pre-service
education, they may have had some degrees in the care of the mother but for most of them,
the competence thus achieved remains irrelevant to newborn care, which is at best inadequate.
In some countries, even after formal training in midwifery, the health worker at the peripheral
level is given a number of additional responsibilities that often have no relevance to the
birthing process but that are overwhelming. As a result, the health worker may forget some of
the skills learnt. The study gave an example citing the auxiliary nurse midwife (ANM) in India
who has many responsibilities related to family planning, immunization and other activities that
have no connection to birthing and care of the newborn infant. In addition, many of the ANMs
do not stay close enough to the village homes to be able to attend the deliveries easily.
Transport is poor and the ANM is not always equipped with the supplies to handle the mother
and the baby efficiently at birth.
Hence, the skilled birth attendant needs to have and maintain — through in-service training,
supervision techniques, and continued practice — skills not only for managing the mother but
also to deal with the baby. Supervision and monitoring of SBAs should include indicators
relevant to both the mother and baby (Narayannan et al. 2005).
There are dire constraints in terms of human resources, although the situation is improving
with higher output of training centers and reduced international migration. Nurse/Midwife
population ratio is currently estimated at 1:1,510 with large disparities for access in favor
of Greater Accra and Kumasi. Ithas been estimated that there is a need for approximately 5,000
new midwives (not yet including the need as identified above, when converting CHPS into
birthing centers).
In terms of increasing the number of newly trained staff, the largest barrier to overcome is the
need for sufficient teachers and trainers who are competent in midwifery theory and in clinical
practice.
To achieve the right balance between numbers and quality, adequate funds and a cost
effectiveness analysis are necessary, in turn dependent upon having policies and strategies in
place (Health Summit Report, November 2010).
Period
2012
2013
2014
2015
Total
Additional maternal
deaths prevented
relative to
impact year
250
380
415
432
1,477
Additional deaths
prevented in babies
aged < 1month relative
to impact year
1,641
2,880
3,512
3,762
11,795
Stillbirths prevented
relative to impact
year
75
141
182
200
598
Most maternal deaths and disabilities could be averted if all births were attended by a skilled
health professional with access to a quality referral facility (FCI 2002).
4. METHODOLOGY
This section details the step-by-step plan as to how the policy simulation exercise will be
conducted. It deals with issues such as source and methods of data collection, the underlying
simulation assumptions, measurement of relative effectiveness, costs of the alternatives,
measurement of equity in the alternatives, paying for the alternatives as well as the sensitivity
analysis.
4.1 Data Sources
The major source of data for this analysis is from the Ministry of Health, Ghana Health Service
and also from the Ghana living Standard Survey (2005). In few cases, some estimates were
made using individual midwife average income and expenditure information.
4.2 Expected Beneficiaries
Number of Women in Fertility
Age (WIFA) 2012 who do not
have access to skilled delivery
864,644
% of WIFA who would
access district hospitals
(Source: EMoNC 2010
Survey)
51.50%
445,292
% of WIFA who would
access health centers
34.6%
299,167
Source: Author Generated
The expected total number of beneficiaries for Policy A is 445,292 and this constitutes 55.5% of
WIFA who do not have access to skilled delivery and would go to district hospitals, while the
total expected number of beneficiaries for Policy B is 299,167 which constitutes 34.6 percent of
WIFA who would go to health centers and other sub-district structures.
4.3 Assumptions











It is assumed that women giving birth would opt for supervised deliveries in preference
to alternatives, provided that barriers of distance, cost and cultural acceptability are
overcome, and if staff in the facilities has the necessary interpersonal skills to support
women.
Zero inflation rate
The capital costs to educate midwives may include school construction and equipment
purchases
The recurrent costs typically to train them include facility costs (operation, maintenance
and supplies), student accommodation and meals, student allowance, staff costs such as
salary, incentives and benefits..
The cost of midwifery kits and cord package is constant for both Policy A and B
The cost of training midwives includes all other administrative costs
No transportation cost for those at the district hospital since bungalows are close to
health facilities
Accommodation at the community level requires transportation to and from health
facility
20 working days in a month
Growth rate for Women in Fertility Age (WIFA) at 1.1 percent based on trend analysis
from 2007 to 2010 (2010 Annual Reviewers Report for Upper East; Ghana Health
Service)
Trained midwives would largely be deployed at district hospitals and health centers
4.4 ANALYSIS APPROACH
4.4.1 Relative Benefits
The benefits would largely consider the deaths averted by instituting both policies and the
lifetime earnings of the beneficiaries of the policy interventions
4.4.2 Relative Costs
The cost for Policy A would involve the total cost of training a midwife, personnel salary,
midwifery kits. In addition to these costs, we would also consider the accommodation of
personnel to the district (Government) bungalow, cost of transportation to the facility.
Policy B would also consider, in addition to the total training cost, personnel salary, midwifery
kits; the accommodation cost at the community level, cost of transportation to the facility. This
implies that both the capital and recurrent cost for both the interventions are the same.
However, the cost of the two programs would vary in terms of the estimated number of people
who visit the district hospital as against those who visit the health center. The detailed cost
breakdown of the interventions is as follows:
Detailed Cost Breakdown for Policy A
UNIT COST per midwife
Source/ Basis
per year
Cost for training midwife
$500.67
The state of the
World’s midwifery
2011 report
Cost of Personnel Salary
$8273
Ghana Health Service
Accommodation cost (usually
$827.3
Interview with
provided with Government
Midwife (10% of
bungalows)
salary)
Total cost for training and
$9600.97
Author’s own
deploying midwives to district
calculation from
hospital
reports and
interviews
Other parameters used
High end: At least 1.88
JLI-WHO benchmark
midwife to 1000 people (Ministry of Health;
Low end: At least 0.3
Human Resource for
midwife to 1000 people Health development;
Annual Report 2011)
Exchange rate: $1 =
Bank of Ghana,
GHS 1.9
November 2012
Discount rate: 10%
Base rate: Cost of
borrowing
COST ITEM
1.
2.
3.
4.
5.
1.
2.
3.
Detailed cost breakdown for Policy B
COST ITEM
UNIT COST per
midwife per year
Cost of training midwife
$500.67
Cost of Personnel Salary
Accommodation cost (usually selfaccommodation at the community
level)
Transportation to health facility
$8273
$189.47
5.
Total Unit cost for training and
deploying midwives to health centres
$9342
6.
Other parameters used
High end: At least
1.88 midwife to 1000
people
Low end: At least 0.3
midwife to 1000
people
Exchange rate: $1 =
GHS 1.9
Discount rate: 10%
4.
$378.9
Source/ Basis
The state of the
world’s midwifery
2011 report
Ghana Health Service
Interview with
midwife at health
center
Interview with
personnel
Author calculation
based from health
reports and
interviews with health
personnel
JLI-WHO benchmark
(Ministry of Health;
Human Resource for
Health development;
Annual Report 2011)
Bank of Ghana,
November 2012
Base rate: Cost of
borrowing
4.4.3 Cost-Effectiveness Analysis
Effectiveness (Additional Women in Fertility (WIFA) Age gaining access to skilled delivery) and
Estimated Cost of Policy Alternative A
Year
2012
2013
2014
2015
Training and deployment of midwives at district hospitals
Projection of WIFA (Beneficiaries)
Average WIFA growth
Projection of WIFA who already have access to
skilled delivery
Projection of pupils who do not have access to
skilled delivery
Policy Simulation objectives ( increasing access to
skilled delivery from current 54% in 2012 to 95%
by 2015)
Additional Average rate to increasing access to
skilled delivery
Policy Simulation objectives ( reducing maternal
mortality rate by 35% from the current 47% rate
for achieving the MDG 5 by 2015)
Additional Average reduction rate to reaching
MDG target
445,292
450,190
455,142
460,149
1.1%
529071
1.1%
534891
1.1%
540775
1.1%
546723
450,190
455,142
460,149
54
64
85
95
-
10
31
41
47
55.7
74
82.7
-
8.7
27
35.7
45,019
141,094
188,661
445,292
Projected increment in WIFA accessing skilled
delivery
Total WIFA who would have access to skilled
delivery after Policy A
-
-
579,910
681,869
735,384
Cost from simulation
Projected annual average inflation
Cost per midwife deployment
US$
9%
9601
8640.9
41
205
1968199
US$
9%
10465.1
9418.6
41
213
2229057
US$
9%
11406.9
10266.2
41
222
2532335
US$
8%
12319.5
11087.5
41
231
2845797
1771379
2006151
2279101 2561217
Present Value (10% discount)
Total number of district hospitals
Total number of midwives deployed
Total Annual (Incremental) cost
Net Present value @ 10% discount rate of Total
Cost
Effectiveness (Additional Women in Fertility (WIFA) Age gaining access to skilled delivery) and
Estimated Cost of Policy Alternative B
2011/
2012/
2013/
2014/
Year
2012
2013
2014
2015
Training and deployment of midwives to Health Centers
299,167 302,458 305,785
309,149
Projection of WIFA (Beneficiaries)
1.1%
1.1%
1.1%
1.1%
Average WIFA growth
Projection of WIFA who already have access to
355454 359364 363317
367313
skilled delivery
Projection of pupils who would not have access to
299,167 302,458 305,785
309,149
skilled delivery
Policy Simulation objectives ( increasing access to
skilled delivery from current 54% in 2012 to 95% by 54
64
85
95
2015)
Additional Average rate to increasing access to
skilled delivery
10
31
41
Projected increment in WIFA accessing skilled
delivery
Total WIFA who would have access to skilled
delivery
Cost from simulation
Projected annual average inflation
Cost per midwife deployment
Present Value (10% discount)
US$
9%
9342
8408
US$
9%
10183
9165
US$
9%
11099
9989
US$
8%
11987
10788
Total number of health centers
435
435
435
435
Total number of midwives deployed
435
452
470
4063770 4602617 5216638
488
5849738
3657393 4142355 4694974
5264764
Annual (Incremental) Total Cost
Net Present value @ 10% discount rate of Total
Cost
4.4.4 Sensitivity Analysis
4.4. 5 Measuring Equity of Alternatives
The benefit would be measured using the equity that would be distributed to the various socioeconomic groups (quintiles) using the Ghana Living Standard Survey (GLSS V), and the total
expenditure for these alternatives.
The benefit would be measured using the benefit-incidence analysis. The equity focuses on the
socio-economic status as measured by income, wealth or consumption, thus spreading benefit
among socio-economic groups to ascertain which income group would experience considerable
impact from the reduction in maternal mortality.
Concentration index which is a quantitative technique for health equity analysis and provides a
means of quantifying the degree of income-related inequality in a specific health variable would
also be used.
4.4.6 Paying for the Alternatives
According to ISODEC/UNICEF budget analysis report (2010), the health sector has received cuts
in expenditure, particularly for investments expenditure. For instance in 2008 actual health
investment expenditure was over 59 percent less than what was budgeted at the beginning of
the year. Furthermore, the actual health investment expenditure in 2008 fell short by about 38
percent of what was actually spent in 2007, and in 2007, this expenditure fell short by about 21
percent of the amount actually spent in 2006 in nominal terms.
This simulation exercise would explore the existing funding mechanisms for the health sector
which are usually internally generated and also through general budget support from donors.
The exercise would also explore the possible areas for the government to raise revenue,
particularly through savings that can be ploughed back into the provision of these health
services. Tax-based financing that is more equitable and progressive, particularly from Ghana’s
extractive sector, could also be explored to provide funding for these policy alternatives.
APPENDIX
Calculation of Expected Beneficiaries
NAME OF REGION
Women in
Fertile Age
(WIFA) as
at 2010
WIFA 2011
(1.1% of
2010
WIFA)5
WIFA 2012
(1.1% of
2011
WIFA)
Number of
WIFA who
had access
to skilled
delivery
(2012)
Number
without
access to
skilled
delivery
Distribution
of trainee
midwives as
at 20116
Upper East
246,350
249,060
251,800
136,727
115,073
113
118
6
33
Upper West
157,646
159,380
161,133
87,495
73,638
165
172
5
56
Northern
527,980
533,788
539,660
293,035
246,625
80
83
9
122
Volta
459,968
465,028
470,143
255,288
214,855
236
245
12
144
Central
459,107
464,157
469,263
254,810
214,453
86
89
9
80
Total
1,851,051
1,871,413
1,891,939
1,027,323
864,644
680
707
41
435
Average skilled delivery
rate for 2012 (based on
2010 projections of the
5 regions)
54.3%
Source: GSS (2010 projection):
 Average number of midwives in a health center = 1
 Average number of midwives in a district hospital = 5
(Source: Interview with Ghana Health Service Personnel)


5
Total Number of midwives = 41*5 = 205 in 2012 to district hospital
Total Number of midwives to health center = 435*1 = 435
All decimals have been converted to the nearest absolute figure
Human Resource for health development ; 2011 Annual Report
7
Assumption based on increment rate in production of midwives from 2009 to 2010; Health Sector Report 2010
8
Annual Reports and 2010 Health Facts and Figures; GSS
6
Distribution
of trainee
midwives
2012 (4% of
2011)7
Number of
district
hospitals
Number
of Health
Centres8
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