A Study of the Drivers of Routine Immunization System Performance in Ghana February 2012 JSI Research & Training Institute, Inc. Arlington, VA ARISE is managed by the JSI Research & Training Institute, Inc. (JSI) and funded by the Bill & Melinda Gates Foundation. JSI’s partners on ARISE are the School of Public Health at Makerere University (Uganda) and the Dartmouth Institute at Dartmouth College (United States) and George Washington University School of Public Health. GHANA COUNTRY REPORT | i Recommended Citation: Larson, A., Kanagat, N., Biellik, R., LaFond, A.K. & Amegah, K. (2012). A Study of the Drivers of Routine Immunization System Performance in Ghana. Arlington, VA: JSI Research & Training Institute, Inc./ARISE Project for the Bill & Melinda Gates Foundation. ARISE Project JSI Research & Training Institute, Inc. 1616 N. Fort Myer Drive, 16th Floor Arlington, Virginia 22209 USA Tel: 1 (703) 528-7474 Email: [email protected] URL: http://arise.jsi.com ii | GHANA COUNTRY REPORT Contents Contents ........................................................................................................................................... iii Acronyms and Abbreviations ........................................................................................................... viii Acknowledgments ........................................................................................................................... 11 Executive Summary .......................................................................................................................... 12 Background ......................................................................................................................................... 12 Methods .............................................................................................................................................. 12 National context ................................................................................................................................. 13 District context .................................................................................................................................... 14 District performance indicators and drivers ....................................................................................... 14 Implications ......................................................................................................................................... 17 Investing in improved performance ................................................................................................... 19 Chapter One: Introduction ............................................................................................................... 20 Introduction to Ghana ................................................................................................................................ 21 Political structure ................................................................................................................................ 22 Economy ............................................................................................................................................. 22 Social and demographic characteristics.............................................................................................. 23 Ghana health system .................................................................................................................................. 23 Health-sector financing ....................................................................................................................... 23 Structure of health services ................................................................................................................ 25 Health workforce ................................................................................................................................ 26 Brief history of the Expanded Programme on Immunization in Ghana ............................................. 27 Chapter Two: Methods..................................................................................................................... 30 District selection ......................................................................................................................................... 31 Research team ............................................................................................................................................ 32 Instruments ................................................................................................................................................. 32 Data collection ............................................................................................................................................ 34 Analysis ....................................................................................................................................................... 35 Chapter Three: District reports ......................................................................................................... 37 Introduction to the districts ........................................................................................................................ 37 Krachi West ................................................................................................................................................. 38 Health service ..................................................................................................................................... 40 District methodology .......................................................................................................................... 41 Routine immunization performance................................................................................................... 41 Driver pathways to high routine immunization coverage .................................................................. 45 GHANA COUNTRY REPORT | iii Summary ............................................................................................................................................. 48 Asikuma-Odoben-Brakwa ........................................................................................................................... 48 Health service ..................................................................................................................................... 49 District methodology .......................................................................................................................... 50 Routine immunization performance................................................................................................... 50 Driver pathways to high routine immunization coverage .................................................................. 53 Summary ............................................................................................................................................. 56 Municipality of Ejisu-Juaben ....................................................................................................................... 57 Health service ..................................................................................................................................... 57 District methodology .......................................................................................................................... 59 Routine immunization performance................................................................................................... 59 Driver pathways to high routine immunization coverage .................................................................. 62 Summary ............................................................................................................................................. 65 Ho municipality ........................................................................................................................................... 65 Health service ..................................................................................................................................... 66 District methodology .......................................................................................................................... 67 Routine immunization performance................................................................................................... 67 Drivers of routine immunization performance ................................................................................... 71 Summary ............................................................................................................................................. 75 Chapter Four: Drivers of routine immunization success in Ghana ...................................................... 76 National-level drivers .................................................................................................................................. 76 A legacy of supportive health policies ................................................................................................ 76 Impact of national-level inputs on district RI performance ................................................................ 79 District health service management drivers ............................................................................................... 82 Leadership and effective management .............................................................................................