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Formative Evaluation Report
for The Project entitled “Accelerating efforts to reduce
maternal, neonatal and child mortality in the Northern and
Upper East regions of Ghana”
Evaluators:
Timothee GANDAHO, MD, PhD,
Samuel BOSOMPRAH, MSc, PhD,
September, 2015
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Table of Contents
Acknowledgements ................................................................................................................... 5
Executive Summary .................................................................................................................. 6 Background ....................................................................................................................................... 6 Key Findings ...................................................................................................................................... 7 Conclusion ......................................................................................................................................... 9 Recommendations .............................................................................................................................. 9
1. Introduction ........................................................................................................................ 13 1.1 Background ................................................................................................................................ 13 1.2 Specific objectives of the formative evaluation: .......................................................................... 14
2. Scope of the Evaluation and Evaluation Questions ............................................................. 15 2.1 Scope of the formative evaluation ............................................................................................... 15 2.2 Evaluation questions: ................................................................................................................. 15
3. Evaluation Methods ............................................................................................................ 20 3.1 Ethical considerations ................................................................................................................ 20 3.2 Study design ............................................................................................................................... 20 3.3 Sample size consideration and sampling ..................................................................................... 21 3.4 Field work/Data collection .......................................................................................................... 22 3.5 Data Analysis .............................................................................................................................. 24 3.6 Data archiving ............................................................................................................................ 24 3.7 Quality Assurance ...................................................................................................................... 24
4. Evaluation findings ............................................................................................................. 26
5. Lessons learned ................................................................................................................... 61
6. Conclusions and Recommendations .................................................................................... 61 6.1 Conclusions ................................................................................................................................ 61 6.2 Recommendations ...................................................................................................................... 62 References........................................................................................................................................ 65
Appendices .............................................................................................................................. 66 AP1. Informed Consent Form .......................................................................................................... 66 AP2. Evaluation tools (In-depth interview guides, Short questionnaires, FGD guide) ...................... 67 AP3. Evaluation Framework ........................................................................................................... 81 AP4. List of National Decision-Makers/Stakeholders Interviewed ................................................... 85
AP5a. Evaluators’ work schedule. ................................................................................................. 87 AP5b. Percentage change in institutional neonatal deaths by districts in the two regions................. 87
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Acronyms and key definitions
Acronyms
ANC Antenatal Care
AP Appendix
BEmONC Basic Emergency Obstetric and Newborn CarCBACommunity Based Agents
CHN Community Health Nurse
CHO Community Health Officer
CHPS Community Health Planning and Services
C4D Communication for Development
DA District Assembly
DHIMS Health Information Management System
DHMT District Health Management Team
EC European Commission
EMBRACE (model) European Model for Bioinformatics Research and Community Education
EmONC Emergency Obstetric and Neonatal Care
FGD Focus Group Discussion
GHS Ghana Health Service
HBPNC Home-Based Postnatal Care
HIV Human Immunodeficiency Virus
HRBA Human Rights-Based Approach
HSS Health Systems strengthening
IMNCI Integrated Management of Neonatal and Childhood Illnesses
JHPIEGO Johns Hopkins Program for International Education in Gynecology
and Obstetrics
JICA Japan International Cooperation Agency
KOICA Korea International Cooperation Agency
KMC Kangaroo Mother Care
LBW Low Birth Weight
MAF MDG5 Acceleration Framework and Action Plan
MDGs Millennium Development Goals
M&E Monitoring and Evaluation
MNCH Maternal Newborn and Child Health
MoH Ministry of Health
NGO Non-Governmental Organization
NBC Newborn care
NCC Newborn care corner
NCU Neonatal Care Unit
NMR Neonatal Mortality Rate
NR Northern Region
OECD/DAC Development Assistance Committee of the Economic Cooperation and
Development
PATH An International Health Organization
PNC Post Natal Care
PPME Public Private M E
QI Quality Improvement
QA Quality Assurance
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UER Upper East Region
UGMS University of Ghana Medical School
UNICEF United Nations Children’s Fund
URC University Research Co, LLC
WHO World Health Organization
UN United Nations
UNFPA United Nations Population Funds
USD United States Dollar
USAID United States Agency for International Development
Key definitions Low birth weight Weight of less than 2,500g, irrespective of gestational age
Newborn death Death within 28 days of birth of any live-born baby regardless of
weight or gestational age
Preterm birth A baby after born less than 37 completed weeks of gestation
Still birth A baby born with no signs of life at, or after 28 weeks' gestation (WHO). -
http://www.who.int/maternal_child_adolescent/epidemiology/stillbirth/en/
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Acknowledgements
The National Newborn Subcommittee members and UNICEF Ghana staff contributed to the
improvement of the evaluation tools, framework, preliminary results and draft report with their
constructive suggestions and comments; the evaluators wish to express their appreciation to them.
The evaluators would particularly like to acknowledge the technical and financial assistance received
from UNICEF for this evaluation.
We would also like to express our sincere gratitude to the experts and national key informants from
MoH, GHS, UNFPA, UNICEF Accra /Tamale, WHO, European Commission, USAID, JICA, the
Embassy of Japan, USAID/HSS Project, USAID/JHPIEGO project, PATH, the Pediatric Society of
Ghana, the Society of Obstetricians and Gynecologists of Ghana, the Ghana Registered Midwife
Association, the Teaching Hospitals, the School of Public Health, Project Fives Alive, the University
of Ghana Medical School (UGMS) and the Coalition of NGOs on Health; who provided valuable
information used for this evaluation.
The contributions of other United Nations agencies and development partners who were key
informants in this evaluation process are also greatly appreciated.
Special thanks to all national, regional and district Leaders or Directors or in-Charge and newborn
care focal persons of Ghana Health Service HQ/NR/UER who were interviewed at national, regional
and district levels. The information they have provided was key to this evaluation.
The evaluators are very grateful to the highly motivated health providers, especially the community
health officers, the community health nurses and midwives of the Northern region and Upper East
region, and to all the mothers who participated with enthusiasm in the focus group discussion sessions
as beneficiaries of newborn care. They have generated critical information for this formative
evaluation for the newborn care project in the Northern and Upper East regions.
Furthermore, we would like to commend the technical support and the valuable and relevant
comments received at various stages of this evaluation from UNICEF Staff – Dr. Hari Krishna
Banskota, Dr. Victor Ngongalah, Dr. Imran Ravji, Mrs. Felicia Mahama, Mrs. Anna Maria Levi, and
Mr. Clemens Gros – and from GHS Staff – Dr. Isabella Sagoe-Moses and Dr. Cynthia Bannerman.
We also extend our appreciation to all who contributed directly or indirectly to this evaluation.
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Executive Summary
Background The death of infants in the first 28 days of life is increasingly becoming a global health concern. This
is especially relevant as it undermines the achievement of the millennium development goal: to reduce
under-five mortality. Many countries in the developing world have, over the years, implemented a
series of interventions to reduce the burden of under-five mortality. In line with the National Child
Health Policy, UNICEF with funding support from the Government of Japan, has been providing
technical and financial assistance to GHS at the National level and in a selection of fourteen districts
of the Northern and Upper East regions of Ghana since October 2011 in order to implement the project
entitled “Accelerating efforts to reduce maternal, neonatal and child mortality in the Northern
and Upper East regions of Ghana”. This project was the subject of this evaluation. The following
are the key findings of the evaluation and recommendations for possible policy action.
The Specific objectives of this formative evaluation are:
1. To ascertain the effectiveness of the package of evidence-based maternal, neonatal and child
survival interventions with a focus on community-based (Home-based Postnatal) Care
(HBPNC) and facility-based integrated Management of Newborn and Childhood Illnesses
approaches in the selected districts of the Northern and Upper East regions;
2. To ascertain the project’s contribution to capacity building that is, developing training
resources and facility structures to respond to the high levels of newborn morbidity and
mortality in the selected districts of the Northern and Upper East regions;
3. To ascertain the effectiveness of the evidence-based advocacy by the project on the national
policy environment on issues related to newborn survival;
4. To draw lessons on the implementation capacity for the national expansion of the essential
newborn care model through home-based early postnatal care.
The scope of the formative evaluation covered the areas of implementation of the project in the two
regions (Northern and Upper East Region) of Ghana and at the national level. The evaluation covered
the two phases of the project from September 2011 to December 2014. The evaluation focused on,
and included the following: final beneficiaries, service providers, actors at the sub-national
decision-making level (district and regional health authorities), actors at the national decision-
making level, national professional societies and academia.
The formative evaluation attempted to provide answers to a number of questions to meet the
Development Assistance Committee of the Economic Cooperation and Development (OECD/DAC)
evaluation criteria as it pertains to relevance, effectiveness, efficiency, and sustainability as well as
UNICEF’s Coherence and Human Rights-Based Approach (HRBA) to Programming and Equity
for all target groups.
The formative evaluation employed a mixed method design consisting of qualitative and
quantitative components. The qualitative component consisted of in-depth interviews with 12 key
national decision-makers, donor partners, 16 sub-national health authorities, 12 service providers and
2 focus group discussion (FGD) sessions with mothers drawn from the communities in the two project
districts. The quantitative component involved abstraction of neonatal health indicators from the
District Health Information Management System (DHIMS 2) and other relevant data sources based
on indicators developed from the evaluation questions as well as project-specifics to assess the
project’s success and effectiveness.
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Key Findings
The main findings are summarized below according to specific evaluation objectives:
Objective 1: To ascertain the effectiveness of the package of evidence-based maternal, neonatal
and child survival interventions with a focus on community-based (Home-based Postnatal) Care
(HBPNC) and facility-based integrated Management of Newborn and Childhood Illnesses approaches
in the selected districts of the Northern and Upper East regions;
The established level-two newborn care units in the district hospitals have contributed, to some
extent, to an improved neonatal survival through an improved management of sick newborn
babies. For example, institutional neonatal deaths per 1,000 live births reduced by about 51% in
the Northern region and about 43% in the Upper East region over the project period (from 2012
to 2014). But challenges still remain with cases from the communities arriving late for
management. However, it should be noted that the project was implemented in well identified
districts and not in the entire region that contains a lot more districts; thus the findings
disaggregated and analyzed by project districts show mixed results.
During FGD, the beneficiaries expressed satisfaction with the home-based care for their babies
received from the CHOs/CHNs. They also indicated having received basic counseling on health
and wellbeing of mothers and babies and that the regular interaction with the CHOs/CHNs and
community volunteers provided the opportunity to share their experience and bring up their
challenges relating to the provision of care for their newborn babies and managing of their own
health.
Perceptions and reported statements from beneficiaries indicate that the health and wellbeing of
babies have improved substantially to their satisfaction. They reported positive behavioral change
and less diseases due to the newborn care intervention, especially education by nurses and
volunteers during home visits and supportive communication activities.
A review of the project proposal indicated that due considerations were given to changes in the
burden of neonatal deaths in the selection of the project regions. It also indicated that the regions
were chosen to consolidate the gains recorded following a series of interventions in the past.
A review of the Medium Term Health Expenditure Plan for 2014-2017 and the Ghana Shared
Growth and Development Agenda for 2014-2017 showed that many activities therein can directly
and indirectly impact the lives of the newborn. The National Newborn Strategy provides a more
focused framework on newborn survival, which can be operationalized through annual plans and
budgets with the support of health partners.
Objective 2: To ascertain the project’s contribution to capacity building that is, developing training
resources and facility structures to respond to the high levels of newborn morbidity and mortality in
the selected districts of the Northern and Upper East regions;
The project supported capacity building workshops for all district directors of health services and
district public health nurses in the project districts on essential newborn care. They are now able
to plan for newborn care activities. A review of the districts’ annual plans showed that they have
all featured newborn care activities. Key informants reported that the project trained sub-national
personnel as trainers who in turn trained sub-district and community health service providers on
newborn care.
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A desk review of project documents showed that a total of 4,151 health workers (369 Doctors,
midwives, medical assistants, nurses, 816 CHOs and CHNs) plus 1748 community volunteers and
1218 Red Cross mother-to-mother support groups with 18 supervisors and facilitators) were
trained on essential newborn care. However, while service providers reported satisfaction with the
training content, the capacity created might diminish over time especially under high attrition
situations. Out of $1,812,187, 45% ($808,356) were spent on training and capacity building and
35% ($617,271) spent for community and facility service delivery and demand generation. The
cost of training a health professional in newborn care was $194.73 on average per trainee.
Key informants, reported that the application of skills and knowledge acquired during the
newborn care trainings reinforced with supervision, monitoring and mentorship have helped to
improve the quality of service delivery by the trained providers.
Some of the beneficiaries reported to have been educated on essential newborn care through
community durbars and information from nurses and volunteers who spent time with them during
home visits.
Objective 3: To ascertain the effectiveness of the project’s evidence-based advocacy for issues
related to newborn survival and national policy environment.
The aim of the project to improve neonatal survival is very much aligned with the national child
health policy. A desk review of relevant policy documents showed that the objectives of the project
were aligned with the Government of Ghana’s Child Health Policy. The project is very much
placed within UNICEF’s global mandate to improve children’s health. The project is operationally
aligned with UNICEF’s significant presence in northern Ghana including a field office in Tamale
with technical and operational staff who provide close technical and monitoring support during
the project. The project is also very well aligned with the EMBRACE model articulated in the
Government of Japan’s Global Health Policy both conceptually as well as operationally.
The project supported the processes leading up to the development and launch of the National
Newborn Strategy and 2014-2018 Action Plan. Specifically, the project supported MoH/GHS to
organize 3 national level stakeholder meetings on newborn health. It also supported the
development of bottleneck analysis tools and decentralized monitoring and planning on newborn
health. As reported by key informants, the launch was very successful, and the advocacy and
communication around it contributed to place newborn health on the national agenda.
The Ministry of health and partners, recommended a newborn strategy and Ghana Health Service
was tasked to have it developed with newborn indicators for performance monitoring. The
national newborn strategy was launched in July 2014. The advocacy and communication around
it was such that it was attended by parliamentarians, civil society, embassy representatives, some
key media personnel and representatives from other sectors. In order to implement the National
Newborn Care Strategy, all 10 regions now have a newborn health focal person.
Objective 4: To draw lessons on the implementation capacity for national scale-up of the essential
newborn care model through home-based early postnatal care.
The Newborn Sub-Committee coordinates newborn care activities of all the partners involved in
implementing newborn interventions. Each region and district has a focal person for newborn
care. The training modules have been adopted and are being rollout to other regions and home
visits are being integrated into the CHPS structure.
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The DHMT/DA is supportive to newborn care but is yet to demonstrate ownership to
consolidate the achievements and the expansion of the newborn health interventions within
available or mobilized resources for the district. Its resources are not sufficient to be able to self-
support the needs for a long-term sustained newborn care intervention. Challenges however
remain. They pertain to the adequate mobilization of resources for such ownership and the
remuneration of community-based volunteers, the building of capacity for new staffs with more
training sessions, more NCU equipment and resolving problems pertaining to fuel and
motorbikes supply for home visits.
Government resources to the sector are limited and remain basic for the regions where the health
services depend on internally generated funds – mainly from the national health insurance
scheme. Unfortunately, the delay in payment by the insurance scheme is further threatening
service provision.
Service providers admit that despite the success of the project, there exist some bottlenecks,
which need to be addressed before scaling-up the essential newborn care model through home-
based early postnatal care. These include lack of motorbikes, insufficient personnel due to staff
attrition or trained nurses going back to school for further training, lack of means of
transportation for supportive supervision or performance monitoring, and volunteer fatigue due
to the absence of incentives. Conclusion
The home-based postnatal newborn care and neonatal intensive care models have been effective in
contributing to improved newborn survival in the two project regions of Upper East and Northern
regions of Ghana, to the extent possible given the scope and reach of the intervention. The enhanced
capacity of NCUs, with essential newborn care equipment as well as the enhanced capacity of health
personnel in terms of skills acquired for management of sick and preterm babies, have been important
enabling factors for saving the lives of many babies in the project districts. The evidence-based
advocacy efforts at all levels contributed significantly to making newborn issues a national priority,
especially culminating in the development and launch of a National Newborn Strategy and Action
Plan.
Recommendations
The challenge for improving newborn health lies in ending preventable newborn deaths and securing
Ghana’s future. Success will be measured in terms of lives saved and lives improved. Success will
depend on meeting the needs of women and their babies throughout the continuum of care and
committing to the following action items:
National Level:
1. The Government should commit enough resources to operationalize the National Newborn
Strategy and Action Plan. The Newborn strategy could be used as a framework for donor
support. Donor assistance should be mapped onto strategy priorities and donor projects have
to be coordinated in order to achieve strategy objectives. A system should be put in place
for the effective monitoring and assessment of achievements and resource management tools
should be setup so as to ensure accountability. A national budget line for newborn activities
needs to be envisioned. An advocacy group may also be put in place to ensure continued
resource mobilization for Newborn Strategy implementation.
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2. The MoH/GHS should ensure that every district hospital has a Newborn Care Unit for
secondary (level 2) care. All regional and teaching hospitals should have Newborn Intensive
care Units (NICU) for tertiary (level 3) care. Health Centers and Polyclinics where delivery
is conducted should be provided with Basic Emergency Obstetric and Newborn Care
(BEmONC) including Newborn Care Corners (NCC).
3. The GHS/MoH should establish resource centres in Regional and Teaching Hospitals along
with NCU, to the extent possible using existing structures, to facilitate on-the-job training
for newborn care. Staff from the resource centres should deliver a transferable skills program
through mentorship and periodic specialists’ visits to lower level facilities.
4. The GHS should scale-up the home-based postnatal newborn care model to all districts in
the regions and to other regions. The evaluators do not anticipate any delay if national and
sub-national decision-makers commit to this course. The materials have already been
developed and lessons learned can speed up a nationwide scale-up. GHS could take
advantage of the fact that in all ten regions, there is ongoing newborn activities in some of
the districts supported by various donors such as UNICEF (2 regions), USAID HSS (5
regions), USAID JHPIEGO (4 regions), PATH (4 regions), JICA (1 region) and KOICA (1
region). This will require coordination and harmonization on a minimum package of
effective newborn care for the reduction of newborn mortality.
5. The MoH should review the curriculum of the Midwifery and Community Health Training
Schools to include issues on newborn care or update and strengthen any existing ones such
as the training programs developed in collaboration with UNICEF and other development
partners using the newborn care training modules, and which have now been accepted as
national documents intended to be rolled out to other parts of the country. The MoH and
GHS should collaborate to formulate and approve a detailed implementation plan and budget
for the integration of the newborn care training package into the pre-service, postgraduate
and continuing education systems. The in-service training should also be reinforced for
those already in the field.
Sub-national (region and district) level:
6. The District Directors should collaborate with the District Assemblies (DA) to ensure that
newborn care issues become a standard agenda on district quarterly review meetings. This
implies advocacy work using neonatal mortality data from the district statistics so as to
inform the DA on the urgency of mobilizing funds to address newborn care issues as a
priority in the district. The DA should have a local budget line for newborn care as a
sustainable financing solution for both maternal and newborn care services within the
district. This will help the district address a number of challenges related to newborn care
activities such as incentive and motivation for volunteers and CHO/CHN, fuel supply and
maintenance for motorbikes used for home visits, and the supply of bicycles for volunteers.
The financial contribution of the district to newborn care activities will encourage
MoH/GHS to be supplemented with the recruitment of additional human resources which
are currently in short supply (nurses, midwives and pediatrician) and provide the needed
equipment such as new motorbikes for facilities and materials for NCU.
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7. Regions and districts could set up a community performance-based financing with
performance reward approach where community volunteers, providers and sub-district
teams will be given money for anticipated performance. An agreement will need to be
established with each district and group of providers to implement newborn care activities
with well-established results and coverage for which funds and financial incentives will be
provided based on performance in terms of percentage of expected results achieved. This
will be an option for better coverage and achievements with newborn care.
8. Institutionalization of perinatal death audit and newborn death audit would be fundamental
to ensure increased attention to newborn care and the causes and circumstances of neonatal
death in order to address them more effectively and reduce neonatal mortality. It will also
help avoid neonatal deaths due to poor performance or mistakes or inappropriate action of
the providers. To prevent those unnecessary neonatal deaths, Regional Health Management
Teams, Hospitals and the MoH/GHS should integrate newborn care indicators to the existing
M&E system to monitor performance, progress, facility neonatal deaths and achievements
in newborn care by providers and volunteers. This could be reinforced with provision of
newborn care registers for hospital, facilities and community visits. Regions and districts
health managers should be encouraged to use effectively these newborn indicators and
newborn death audit results in planning and implementation of health service decisions as
well as in assessing staff performance.
9. Regional and district leadership should be strengthened to drive the newborn agenda and
provide support for its implementation. The district directors should be tasked to develop a
comprehensive plan with costing for capacity building and refresher training schedules for
staff involved in newborn care. They must maintain a register of staff and track staff
movement in order to manage any capacity gap arising so as to reduce staff attrition. Further
steps should be taken to provide the necessary conditions to retain trained service providers
in the deprived communities. Part of the available resources should be used for incentive
and motivation of volunteers and CHO/CHN to do more home visits. Regional and district
leadership should reinforce the home-based postnatal care as part of routine activities and
demand accountability from the CHOs/CHNs by periodically assessing their home visit
registers. The number of newborns visited at home at day 3 and day 7 within 0-7 days
following birth should be included in the performance appraisal of the CHOs and CHNs.
Cross Sectoral Support:
10. Quality Assurance (QA), Quality Improvement (QI) and access to quality newborn care
services are important instruments that need to be deployed to attain the MDGs. MoH/GHS
is already putting in place a QA/QI system for health service delivery. This should be
extended to newborn care services at all levels, including at the facility levels with providers
and at the community level with volunteers. There should be an external and internal
newborn care quality audit system. The proposed system will increase competition and
motivate staff to better perform. It should also provide the needed supportive supervision
and mentorship to improve the quality of the newborn care services offered by the health
providers.
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11. National and subnational levels should support effective documentation, communication
and advocacy activities for newborn care. They should develop a communication strategy
for newborn care with a costed implementation plan. Further steps should be taken to
document newborn stories in the field (what is happening? what is new?) then record them
and use media to disseminate them. With support from local community members they
should document bad perceptions towards newborns especially neonates, negative
sociocultural practices and address them with behavioral communication, education of
mothers, husbands, in-laws and families during home visits and social/community
mobilization. They should also intensify health education involving community members,
opinion leaders, traditional and religious leaders to recognize the importance of care
requirements for newborns and mothers in order to improve survival rates. They should
consolidate the gains in C4D activities on newborn care using community volunteers in
order the generate demand. This will require the involvement of the District Assemblies to
motivate the volunteers actively involved in C4D to ensure that they continue the home-
based newborn care activities.
12. National and subnational levels should support secondary data analysis to identify barriers
to newborn care and address them and use operational research results to put more evidence
on the table in order to support the mobilization of funds and advocacy for newborn care.
Steps should be taken to address the issue of gender and ensure greater male involvement.
A human rights-based approach and equity should be part of the sub-national
implementation of newborn care activities. A system that will contribute to the sustainability
of newborn care activities and use quality improvement method at facility level with rewards
to regions, districts and selected providers that are improving newborn care should be
implemented.
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1. Introduction
1.1 Background
The days and weeks following childbirth – the postnatal period – is a critical phase in the lives of
mothers and newborn babies. Major changes occur during this period, which determine the wellbeing
of mothers and newborns. Yet, this is the most neglected time with regard to the provision of quality
services. Lack of appropriate care during this period could result in significant ill health and even
death. Most infant deaths occur during this time. The number of child deaths worldwide has declined
markedly in recent decades, largely through interventions to lower mortality after the first month of
life. The mortality rate among children under five years of age has fallen globally by 47% (from 90
deaths per 1000 live births in 1990 to 48 deaths per 1000 live births in 2012), but the neonatal
mortality rate (NMR) decreased only by 37% (from 33 deaths per 1 000 live births to 21 deaths per
1000 live births) over the same period and represented, in 2012, 44% of the total under five mortality
[1]. The global annual average rate of reduction in NMR since 1990 has been 2.0%, lower than that
of maternal mortality (2.6%) and under-five-year old mortality (2.9%) [2].
In Ghana, around 38 per cent of under-five deaths and 60 per cent of infant deaths occur during the
newborn period. According to the 2011 Multiple Indicator Cluster Survey, the U5MR was estimated
at 82 deaths per 1000 live births – that means 82,000 children die before reaching 5 years. Out of
these, 32, 000 die in the newborn period resulting in a neonatal mortality rate of 32 neonatal deaths
per 1000 live births [3]. An Emergency Obstetric and Neonatal Care (EmONC) assessment conducted
by the Ghana Health Service (GHS) in 2010 reported birth asphyxia as the major cause of intra-partum
neonatal death (41 per cent) at the facility level [4]. This is different than global causes where
prematurity is a major cause. In Ghana, however, birth asphyxia as major cause suggests that there is
an issue of quality of care at the facility level. It is thus critical to respond to these major causes of
neonatal deaths in order to accelerate neonatal mortality reduction.
The global response to end preventable newborn deaths led to the launch of a Global Newborn Action
Plan in June 2014 [5]. Targets have been set to reduce mortality rates and WHO and UNICEF lead
this work. This plan is bold and calls for a global Neonatal Mortality rate of 7 per 1000 live births by
2035. In Ghana, a number of policy responses were initiated including development of a National
Child Health Policy (2007-2015), which provides the framework to improve child survival along the
continuum of care for mother and child and MDG5 Acceleration Framework and Action Plan (MAF)
2011, which identified and prioritized three key areas of intervention: family planning, skilled
delivery, and EmONC for saving the lives of mothers and babies [6]. The Health Sector Medium-
Term Development Plan, 2014-2017 has also outlined improvement of access and quality of maternal
and newborn care as one of the critical interventions.
In line with the National Child Health Policy, UNICEF with funding support from the Government
of Japan has been providing technical and financial assistance to Ghana Health Service at the National
level and in a select fourteen districts of Northern and Upper East regions since October 2011 to
implement the project entitled “Accelerating efforts to reduce maternal, neonatal and child
mortality in the Northern and Upper East regions of Ghana”. The project was implemented in
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two phases. Phase 1 covered the period September 2011 to December 2013 in 11 districts in the
Northern and Upper East regions whereas phase 2 started in January 2013 and ended in December
2014 in the same focus districts as phase 1, but with the addition of three new districts in the Upper
East region resulting in a total of fourteen project districts. The key components of the project
included:
Minimum of two home visits (to mother and newborn) within the first 7 days after delivery
by appropriately trained community health workers;
Integrated Management of Neonatal and Childhood Illnesses (IMNCI) at facility and
community levels;
Scale up of Basic Emergency Obstetric and Newborn Care (BEmONC) at Community Health
Planning and Services (CHPS) and Health Centres;
Developing capacities on life-saving skills for midwives;
Promotion of key household and community practices related to delivery and newborn care;
Leveraging existing resources and initiatives in the project area;
Using a systems strengthening approach to enable sustainability beyond project period
To provide evidence on the effectiveness of this project for possible scale-up, an independent
formative evaluation was commissioned with funding from UNICEF Ghana. The aim of this
formative evaluation is to assess key components of the project.
1.2 Specific objectives of the formative evaluation:
1. To ascertain the effectiveness of the package of evidence-based maternal, neonatal and child
survival interventions with a focus on community-based care (Home-based Postnatal Care
(HBPNC)) and facility-based integrated Management of Newborn and Childhood Illnesses
approaches in the selected districts of the Northern and Upper East regions;
2. To ascertain the project’s contribution for capacity building, developing training resources
and facility structures to respond to the high levels of newborn morbidity and mortality in
selected districts of the Northern and Upper East regions;
3. To ascertain the effectiveness of the project’s evidence-based advocacy for issues related to
newborn survival and national policy environment,
4. To draw lessons on the implementation capacity for national scale-up of the essential
newborn care model through home-based early postnatal care.
15
2. Scope of the Evaluation and Evaluation Questions
It is expected that the project partners– Ministry of Health (MoH), GHS, UNICEF and JICA – will
use the findings of the evaluation in their different capacities and functions, to develop future plans
and interventions and to inform policies and strategies.
2.1 Scope of the formative evaluation
The scope of the formative evaluation covered the areas of implementation of the project in the two
regions (Northern and Upper East Region) of Ghana. This evaluation also expanded its scope to the
national level, to ascertain its sphere of influence on the overall maternal newborn and child health
(MNCH) programming in Ghana. The evaluation covered the overall Government of Japan, UNICEF
and Government of Ghana’s partnership on the newborn health programming from the two phases of
the project from September 2011 to December 2014.
The evaluation focused on, and included the following beneficiaries and stakeholders in the process:
Final beneficiaries: newborn babies, mothers and caregivers;
Service providers: healthcare professionals whose capacity had been built (including doctors,
midwives, community health nurses and sub-district health professionals);
Sub-national decision-making level: District and Regional health authorities;
National decision-making level: national authorities and key stakeholders (MoH, GHS,
Development Partners – JICA, USAID, EC, PATH, JHPIEGO, UN System- UNICEF, WHO,
UNFPA, National Newborn Care committee);
National Professional Societies and Academia: Paediatric Society of Ghana, Society of
Obstetricians and Gynaecologists of Ghana, Ghana Registered Midwife Association, Teaching
Hospitals, School of Public Health.
2.2 Evaluation questions:
The formative evaluation attempted to provide answers to a number of questions to meet
Development Assistance Committee of the Economic Cooperation and Development (OECD/DAC)
evaluation criteria of relevance, effectiveness, efficiency, and sustainability including UNICEF’s
Coherence and Human Rights-Based Approach (HRBA) to Programming and Equity for all target
groups. Following an inception meeting with the National Newborn Sub-Committee and other
stakeholders at the national level, the evaluation questions were reviewed using the Terms of
Reference as the basis (See Table 2.1).
16
Table 2.1: Evaluation criteria, targets and questions
Criteria Questions/Target groups
Relevance National decision-making level: Is the intervention relevant in terms of alignment of project objectives with national
strategy and stakeholder’s priority and needs?
Effectiveness:
National decision-making level: To what extent has the project contributed to the policy direction of the National
Newborn Strategy and Action Plan in terms of advocating for and facilitating to bring
newborn health onto the national agenda of MNCH Programming?
Sub-national decision-making level: To what extent has the project contributed to strengthen capacity of regional health
management teams and district health management teams for planning, informed
decision making and prioritization of the newborn health as per the National Child
Health Policy (2007-2015) and other national guidelines and protocols?
Service providers’ level: To what extent are the established level-two (without ventilator and incubators)
newborn care units in six District Hospitals perceived to have improved the
management and survival of sick newborn babies? Which are the
enabling/constraining factors that facilitated/hindered the management of sick
newborn babies in District Hospitals?
To what extent has there been an improvement in quality of care during post-natal
care in the health facilities targeted by the project?
To what extent has the training and mentorship component of the project responded
to capacity building needs of the different levels of service providers?
Final beneficiaries’ level: To what extent do beneficiaries report to have been reached by project
communication and social mobilization interventions, like community durbars,
mother support groups, community-based agents (CBA) and Red Cross mothers (in
the Upper East Region)?
To what extent do beneficiaries report an improvement in their newborn care and
health seeking practices (ANC, PNC, well baby clinic) as a consequence of improved
counseling by Community Health Officer (CHO)/Community Health Nurse (CHN),
CBA, Red Cross mothers and mother support groups?
To what extent has the intervention contributed to improve health and wellbeing of
newborn babies?
Efficiency:
National level: Were the allocated resources used efficiently to achieve the project objectives? Are
the available resources adequate to meet project needs?
Sustainability:
National level: Have policy makers at MoH/GHS demonstrated ownership over the different
interventions related to newborn survival?
Has the Government of Ghana prioritized the health and wellbeing of newborn
babies in the government’s policy documents (Ghana Shared Growth and
17
Development Agenda for 2014-2017, Medium Term Health Expenditure Plan for
2014-2017) and allocation of resources (budget line on approved Ministry of Health
budget) for newborn health?
Sub-national decision-making level: Have District Health Management Team (DHMT) and District Assembly (DA)
demonstrated ownership and capacity for resource mobilization to be able to self-
support and consolidate the achievements and the expansion of newborn health
interventions?
Service providers’ level: Can the commitment and motivation of CHO/CHN and community volunteers that
were enhanced through the project last for a continued provision of home-based
services to mothers and their newborn babies? What are the bottlenecks and barriers
for home-based postnatal care within the framework of continuum of MNCH care?
Final beneficiaries’ level:
Can the behavioral changes among beneficiaries on essential newborn care be
sustained?
Coherence: National Has the project facilitated synergies and avoided duplications with interventions and
strategies promoted by other UN agencies and development partners (JICA, USAID,
EC, PATH and others) within the National Child Health Policy 2007-2015 and MAF?
Has the project given due importance to donor’s (Government of Japan) visibility in
line with UNICEF’s donor visibility guidelines;
Human rights-
based
approach
(HRBA):
National Has the project incorporated the HRBA to programming?
Has the project considered the equity approach (i.e. focus on most deprived areas,
areas with high prevalence of critical newborn and under-five mortality, low income
families) as well as facilitated the reduction of access barriers to MNCH services by
the target group?
Criteria Questions/Target groups
Relevance National decision-making level: Is the intervention relevant in terms of alignment of project objectives with national
strategy and stakeholder’s priority and needs?
18
Effectiveness:
National decision-making level: To what extent has the project contributed to the policy direction of the National
Newborn Strategy and Action Plan in terms of advocating for and facilitating to bring
newborn health onto the national agenda of MNCH Programming?
Sub-national decision-making level: To what extent has the project contributed to strengthen capacity of regional health
management teams and district health management teams for planning, informed
decision making and prioritization of the newborn health as per the National Child
Health Policy (2007-2015) and other national guidelines and protocols?
Service providers’ level: To what extent are the established level-two (without ventilator and incubators)
newborn care units in six District Hospitals perceived to have improved the
management and survival of sick newborn babies? Which are the
enabling/constraining factors that facilitated/hindered the management of sick
newborn babies in District Hospitals?
To what extent has there been an improvement in quality of care during post-natal
care in the health facilities targeted by the project?
To what extent has the training and mentorship component of the project responded
to capacity building needs of the different levels of service providers?
Final beneficiaries’ level: To what extent do beneficiaries report to have been reached by project
communication and social mobilization interventions, like community durbars,
mother support groups, community-based agents (CBA) and Red Cross mothers (in
Upper East Region)?
To what extent do beneficiaries report an improvement in their newborn care and
health seeking practices (ANC, PNC, well baby clinic) as a consequence of improved
counseling by Community Health Officer (CHO)/Community Health Nurse (CHN),
CBA, Red Cross mothers and mother support groups?
To what extent has the intervention contributed to improve health and wellbeing of
newborn babies?
Efficiency:
National level: Were the allocated resources used efficiently to achieve the project objectives? Are
the available resources adequate to meet project needs?
Sustainability:
National level: Have policy makers at MoH/GHS demonstrated ownership over the different
interventions related to newborn survival?
Has the Government of Ghana prioritized the health and wellbeing of newborn
babies in the government’s policy documents (Ghana Shared Growth and
Development Agenda for 2014-2017, Medium Term Health Expenditure Plan for
2014-2017) and allocation of resources (budget line on approved Ministry of Health
budget) for newborn health?
Sub-national decision-making level: Have District Health Management Team (DHMT) and District Assembly (DA)
demonstrated ownership and capacity for resource mobilization to be able to self-
support and consolidate the achievements and the expansion of newborn health
interventions?
19
Service providers’ level: Can the commitment and motivation of CHO/CHN and community volunteers that
were enhanced through the project last for a continued provision of home-based
services to mothers and their newborn babies? What are the bottlenecks and barriers
for home-based postnatal care within the framework of continuum of MNCH care?
Final beneficiaries’ level:
Can the behavioral changes among beneficiaries on essential newborn care be
sustained?
Coherence: National Has the project facilitated synergies and avoided duplications with interventions and
strategies promoted by other UN agencies and development partners (JICA, USAID,
EC, PATH and others) within the National Child Health Policy 2007-2015 and MAF?
Has the project given due importance to donor’s (Government of Japan) visibility in
line with UNICEF’s donor visibility guidelines;
Human rights-
based
approach
(HRBA):
National Has the project incorporated the HRBA to programming?
Has the project considered the equity approach (i.e. focus on most deprived areas,
areas with high prevalence of critical newborn and under-5 mortality, low income
families) as well as facilitated the reduction of access barriers to MNCH services by
the target group?
20
3. Evaluation Methods
3.1 Ethical considerations
Individual consent was obtained before interviews or focus group discussion (FGD) were conducted.
Each participant was told the purpose and use of the information being collected by the evaluator.
Questions were posed to collect their opinions and views about the activities of the newborn projects
and their possible impact on newborn health indicators. Before the start of the interview or FGD,
participants were told that their participation was voluntary and that they were free to withdraw from
the interview or FGD at any time. They were also told that the information provided would remain
confidential and used anonymously. Participant who gave their consent were given an informed
consent form for signature (See Appendix AP1). Interviews and FGD were conducted in a private and
isolated place to ensure confidentiality and provide a comfortable environment. Evaluators did not
seek personal information, or opinions believed to be controversial. No risk is expected for
participants since the main aim of the evaluation is to improve newborn health (See Appendix AP2a0).
3.2 Study design
The formative evaluation employed a mixed method design consisting of qualitative and quantitative
components. The qualitative component consisted of in-depth interviews with key national decision-
makers, donor partners, sub-national authorities and service providers, and focus group discussions
(FGD) with mothers or caregivers drawn from the communities in one project district. Interview
guides (See Appendices AP2a1, AP2b1, AP2c1) and the FGD guide (See Appendix AP2d) were
developed for the in-depth interviews and FGDs respectively, based on the evaluation questions along
the OECD/DAC evaluation criteria for relevance, effectiveness, efficiency, and sustainability. It
also considered the two additional criteria of interest to UNICEF namely: Coherence and Human
Right-Based Approach to Programming and Equity.
The interview guides were translated into semi-structured questionnaires (See Appendices AP2a2,
AP2b2, AP2c2) with Likert scale responses (i.e. 1=fully disagree; 2=disagree; 3=no opinion; 4=agree;
5=fully agree) to quantify the degree of agreement, or disagreement to a set of statements or
declarations drawn from the interview guides. Respondents, were however, not prompted for the
reasons of their disagreement or their lack of opinion. The questionnaire was administered to as many
stakeholders and service providers as possible including those who took part in the in-depth
interviews. These questions were first pre-tested for their validity and their ability to elicit the right
kind of responses, they were then reviewed (as necessary) prior to being finalized for the main
fieldwork.
The quantitative component involved the abstraction of neonatal health indicators from the District
Health Information Management System (DHIMS (2) and other relevant data sources based on
indicators developed from the evaluation questions as well as project-specifics to assess the project’s
success and effectiveness. Service output indicators were extracted for the region as well as the project
districts. Due to the rarity of certain events, impact indicators such as neonatal deaths per 1,000 live
births were extracted as a regional level indicator for analysis.
21
3.3 Sample size consideration and sampling
For the quantitative component, all 14 project districts were included in the extraction of key neonatal
health indicators.
For the qualitative component, in-depth information were collected from key target groups. Since this
was a qualitative research with recorded interviews, the evaluation team planned to carry total number
of interviews, for the entire evaluation exercise, of less than 45 for the two regions including FGD
sessions and at the national level but with adequate representation of all levels of the target groups.
At the national level, 12 key informants (See Appendix AP4) were contacted for in-depth interviews
in consultation with UNICEF Team. For the two regions, sampling for the in-depth interviews and
FGD sessions happened in two steps. First, the 7 districts in each project region were stratified
according to agreed criteria with stakeholders (Urban with hospital where there is a Neonatal Care
Unit, Rural with hospital, and Rural without hospital). One district was randomly selected from each
of this stratum giving a total of 3 districts for the interviews or FGD. If a stratum had only one district,
that district was included by default. The results of the selection were Kpandai, Savelugu-Nanton and
Tolon-Kumbungu in the Northern region, and Bolga Municipal, Kasena-Nankana West and Talensi-
Nabdam in the Upper East region. However, after a meeting between the evaluation team and the
regional director in the Northern Region, it was agreed to replace Kpandai with Bole since Bole and
Kpandai shared similarities in their performance for newborn care, but Bole had more frequent and
active home-based visits and social mobilizations compared to other selected sites. Having Bole
would cover that aspect of home visits as a key component of newborn care. Talensi-Nabdam was
also replaced with Bawku West in consultation with the regional director of the Upper East Region,
because the evaluation team thought that it was better to have representation of the districts that
experienced the two phases of the project.
Afterwards, 2 facilities (1 Health centre and 1 CHPS compound) were selected in consultation with
the District Director based on the fact that the facility in-charge (Midwife or CHO) had been in post
for the duration of the project. The midwife, CHN or CHO in each selected facility was contacted for
an in-depth interview. For the final beneficiaries in Bolga and in Savelugu districts, the evaluation
team, in consultation with the regional director, agreed to draw 8 to 12 mothers of newborn babies
from the communities with the assistance of the district director and community health officers. The
CHO explained the aim of the FGD to them, and upon obtaining their consent, they were asked to
report to the sub-district health centre. At the health centre, the evaluation team sought their consent
to participate in a FGD session. Drawing the mothers from the project communities was preferred to
the proposed approach of selecting PNC registrants from a NCU facility due to the possibility of
sickness of the mothers’ babies which may result in a state of distress, thus corroding their ability to
participate in a FGD. The regional directors in the project regions and the district directors in the
selected districts were also interviewed. These amount to a total of 28 in-depth interviews and two
FGDs carried out (Table 3.1).
22
Table 3.1: Sample size for the in-depth interviews and focus group discussions among
sub-national, service providers, and final beneficiary target groups
Region Selected districts
Number of In-depth interviews Number
of FGDs
Total
Regional
Director/
NBC
Coordinator
District
Director/
NBC
Coordinator
Midwife
/CHO/
CHN
Northern Bole 2 2 2 6
Northern Savelugu-Nanton 2 2 1 5
Northern Tolon-Kumbungu 2 2 4
Upper East Bolga Municipal 2 2 2 1 7
Upper East Kasena Nankana West 2 2 4
Upper East Bawku West 2 2 4
Total 4 12 12 2 30
3.4 Field work/Data collection
For the quantitative component of the evaluation, key neonatal health indicators at the district level –
for all the 14 project districts – and at the regional level were extracted from DHIMS (2) over the
period spanning from 2011 to 2014 and submitted to consultants through a formal request by UNICEF
Ghana to the Director-General of the Ghana Health Service. Two NCU facilities (one in each project
region) were visited to assess their capacity for newborn care particularly focusing on referral-in and
referral-out indicators.
For the qualitative data, the evaluation team had in-depth interviews with 12 key national decision
makers and health partners. Following this, the evaluation team made a two-week field visit to six
districts in the two project regions and had in-depth interviews with sub-national authorities and
service providers as well as FGD with women beneficiaries. Table 3.2 in the appendix AP5a shows
the work schedule of the consultants.
23
Figure 3.1: Maps of the Northern and Upper East regions with the
14 districts of newborn care intervention and 6 selected districts for interviews.
DISTRICTS OF THE NORTHERN REGION
Districts are colored for emphasis
DISTRICTS OF THE UPPER EAST REGION
Districts are colored for emphasis
24
3.5 Data Analysis
For the quantitative component, indicators were defined for each evaluation question (where
appropriate). The percentage change in key newborn health indicators over the period spanning from
2012 to 2014 was estimated to ascertain the effect of the project in improving newborn survival.
Where the rate of change in the indicator in the project districts was faster than that in the entire region
over the same period, it was suggestive of the intervention being effective. Also, examining coverage
trends was essential for assessing project progress. Information on trends required at least two
separate and comparable measurements at two points in time. A measure of progress – the coverage
gap – defined as how much coverage would need to increase from the 2013 level to reach universal
coverage was estimated to examine coverage trends. The change from 2013 to 2014 was then
expressed as a percentage of this gap.
For the qualitative data, recorded interviews were transcribed verbatim. Data were analyzed manually
using two analytic approaches, namely: (1) Thematic analysis – looking for themes and patterns
among data (verification); and (2) Narrative analysis – in order to identify narratives or cases, and
explore how they differed between groups. No qualitative data analysis software was used for this
evaluation. The ideas, views, opinions and quotations from the transcribed (verbatim) data summaries
and the notes, were used to illustrate the reports by evaluation criteria. For the focus group discussion,
a Matrix for assessing the level of consensus in the focus group was used (Table 3.2). Data from the
semi-structured questionnaires were summarized using proportion of respondents with degree of
agreement or disagreement to a set of statements or declarations.
Table 3.2: Matrix for assessing level of consensus in focus group discussion
Focus
Group
Question
Member 1 Member 2 Member 3 Member 4 Member 5
1
2
3 The following notations were entered in the cells:
A = Indicated agreement (i.e., verbal or nonverbal) D = Indicated dissent (i.e., verbal or nonverbal)
SE = Provided significant statement or example suggesting agreement
SD = Provided significant statement or example suggesting dissent
NR = Did not indicate agreement or dissent (i.e., nonresponse)
3.6 Data archiving
All data collected during this evaluation exercise including recorded interviews (in MP4 format) and
transcribed data (in Word format and electronic version) were submitted to UNICEF Ghana Office
for archiving.
3.7 Quality Assurance
Researchers took appropriate and necessary measures to ensure the quality of the data collected from
the key informant interviews by minimizing ambiguity when presenting the questions to the
25
interviewees. As in many health information systems, the researchers recognized the limitations of
the quantitative data extracted from the DHIMS (2) and tried – within the limited time for this exercise
– to validate suspected figures with facility records.
Researchers also recognized the limitations of in-depth interviews and FGDs in terms of the small
sample size or the limited number of participants interviewed. The information collected was
therefore analyzed and interpreted within their contextual thematic scheme and the individual
opinions and views expressed.
3.8 Challenges and limitations
As mentioned in section 3.7, extracting quantitative data from the DHIMS may have posed some
limitations relating to the completeness and accuracy of the data. Researchers used other sources
whenever possible to validate suspected figures.
Qualitative data have their own limitations in terms of sample size and generalization to the entire
population under study. For this evaluation, opinions and views collected during in-depth interviews
and FGDs with limited number of participants were therefore analyzed and interpreted within that
context of individual ideas and appreciations.
In the absence of control areas, it is difficult to attribute observed changes and achievements entirely
to implementation of the newborn care project which did not cover all the districts in each region.
However, examining changes from one period to another and trends over a period of time is bound to
assess the contribution of the NBC project when quantitative data is available.
The replacement of Kpandai district with Bole district which had very active home visits and social
mobilization may be seen as bias. This choice by the evaluation team and regional authorities offers
the advantage to better assess potential contribution of social mobilization to improving newborn
health in addition to home based care.
26
4. Evaluation findings
This chapter presents the results of the evaluation exercise organized by four evaluation objectives
taking into account the evaluation criteria. For each of the four evaluation objectives and the relevant
evaluation criterion the evaluation finding was quoted and the available evidence was provided as an
explanation. The available evidence was gathered from the desk review, DHIMS (2)/facility records,
semi-structured questionnaires, in-depth interviews and the focused group discussions.
Objective 1: To ascertain the effectiveness of the package of evidence-based maternal, neonatal
and child survival interventions with a focus on community-based (Home-based Postnatal) Care
(HBPNC) and facility-based integrated Management of Newborn and Childhood Illnesses approaches
in the selected districts of the Northern and Upper East regions;
The established level-two newborn care units in District Hospitals have contributed, to some
extent, to an improved neonatal survival through an improved management of sick newborn
babies. However, challenges such as cases from the communities arriving late for management
still remain.
For example, institutional neonatal deaths per 1,000 live births reduced by about 51% (6.9‰ to 3.4‰)
in the Northern region and by about 43% (5.8‰ to 3.3‰) in the Upper East region over the project
period spanning from 2012 to 2014 (Figure 4.4). However, it should be noted that the project was
implemented in well identified districts and not in the entire region which contains several more
districts. Disaggregated and analyzed by project district, these findings show mixed results and are
presented in table 4.1 in the appendix AP5a.
The evidence from one neonatal care unit suggests improved management and survival of sick
newborns. For example, the NCU at Bolgatanga Regional Hospital in the Upper East recorded
downward trends in neonatal deaths per total admission since the start of the NCU in January 2014
(Figure 4.4a). It is possible that the skills acquired during the training are being applied in managing
sick babies referred to the NCU. However, there appeared to be stagnation in the Savelugu District
Hospital NCU in the Northern region (Figure 4.4a). A well-conducted death audits would bring out
the reasons for such a stagnation.
27
Figure 4.4: Percentage change in institutional neonatal deaths per 1,000 live births over the
2012-2014 period in the project regions.
There was a general view among service providers (27 out of 32) that the established level-two
newborn care units in Hospitals improved the management and survival of sick newborn babies
(Figure 4.4b). However, three of them disagreed and two had no opinion probably because of the
challenges.
28
The major element of success with NCU is the supply of equipment for saving the lives of preterm
babies, low birth weight babies, and babies with hypothermia or asphyxia. This equipment included
the resuscitation machine, the incubator, the baby warmer and the phototherapy machine. Other
important elements are the Kangaroo mother care, the body temperature controller, the Random blood
sugar test, the oxygen concentrator, and the fluid therapy.
The midwives in two NCUs assessed during the field visit mentioned some factors as having
contributed greatly to the reduction in neonatal deaths in the facilities. However, the statistics from
the facilities were not available to the evaluators to illustrate the impact of the equipment in the NCU
on the survival of premature newborns as stated by the midwives.
In spite of these achievements there remains serious challenges at the NCU in terms of staff attrition
– a number of staff trained in newborn care have left following their posting elsewhere or to further
their studies. For example, in the Upper East region out of 6 staff trained who started the NCU, only
3 were still working in the NCU during this evaluation. The other challenge is the lack of oxygen
cylinders. UNICEF brought more oxygen concentrators to the NCU. Participants also mentioned the
breakdown of the incubators, which they have no local capacity to repair. The administration was,
however, in contact with Accra which deployed a technician to repair the malfunctioning device.
Strategies to educate mothers to leave their babies in the NCU is also a challenge. This is because
mothers do not like to be separated from their babies at the hospital. This highlights the need to have
room in the facilities for mothers to stay. Sometimes, staff run out of key medicines for the newborn
and have to prescribe them. The Northern Region also faces some challenges as stated in the quote
below:
The beneficiaries expressed satisfaction with the home-based care their babies received from
the CHOs/CHNs. They also indicated that they received basic counseling on health and
wellbeing of mothers and babies and that the regular interaction with the CHOs/CHNs and
community volunteers provided the opportunity to share their experience and bring up their
challenges on providing care to their newborn babies, and taking care of their own health.
The results suggest that through sustained counseling and communication for development activities,
mothers were informed on the importance of kangaroo mother care to ensure the survival of low birth
weight babies.
“Another challenge is the space available for NCU which is too small. Normally when
babies are referred to us from home, we are not supposed to put them together with those
babies born in the hospital, but with limited space we have no choice than to put them
together. We also need a pediatrician for our NCU so that the cases we now refer to Tamale
Teaching Hospital can stay with us. Most of our client mothers do not like to be referred.”
(Provider of NCU in the Northern region)
29
FGD mothers in the Northern region told us that they now report diarrhea cases, vomiting and fever
to the health facility and found that the treatments at the facility were effective to stop sickness in the
child. They emphasized that when they applied what they have learnt, they found that babies were no
longer falling sick and both mother and baby were in good health. This is in line with improvements
in newborn care and health seeking practices reported by the beneficiary mothers. The quote below
from a mother in the Upper East is reinforcing the observed improvements.
Table 4.3:Trends in uptake of kangaroo mother care, Half Year (HY) 2011 to
2014, Upper East region
Indicators 2011
HY
2012
HY
2013
HY
2014
HY
% change
(2014 vs 2013)
No. LBW Babies 912 963 1,138 1,297
% LBW 6.7 8.8 10.3 8
No. on KMC 99 175 249 536
% of LBW on KMC 10.9 18.2 21.9 41.3 88.9
Source: regional statistics data
“From the pictures we learnt that after using toilet we should wash our hands before
touching the baby and also before breastfeeding the baby. Putting all these into practice
helped us to keep the child away from sickness. Before many pregnant women were
delivering at home. These days more women are delivering in health facilities and we no
more see mothers and babies dying when we give birth there.”
(FGD participant, Upper East region)
30
Photo 4: A Focus Group Discussion session in Upper East Region, 17th January 2015
Perceptions and reported statements from beneficiaries are that the health and wellbeing of
babies have improved substantially to their satisfaction. They reported positive behavioral
changes and less diseases due to the newborn care intervention – especially education by the
nurses and volunteers during home visits and supportive communication activities.
CHO and CHNs focused on improving the quality of newborn care provided during the postnatal
home visit. The long-term expectation is that every newborn will receive home-based care by a trained
health worker. In the Northern region, the percentage of babies visited at home by trained health
workers increased from about 30% in 2013 to 37% in 2014, representing a 10.5% gap closed to
achieve universal coverage of all newborn with home-based care (Table 4.4). The Saboba district was
the highest performer (53.8% of gap closed) with Yendi being the worst performer, which recorded a
reduction in home-based visits. In the Upper East region, the percentage of babies visited at home by
trained health workers increased from about 39% in 2013 to 58% in 2014, representing a 30% of gap
closed to achieve universal coverage of all newborn with home-based care (Table 4.4). Bawku West
was the highest performer with 45% of gap closed.
31
The strategy of using community volunteers, who are very familiar with the communities and persons
within the communities, as agents to identify households where pregnant women are, and where
recent deliveries have occurred and inform and link-up with the CHOs/CHNs for scheduled visits was
an enabling factor for the home-based postnatal newborn care.
Table 4.4: Percentage of newborn babies who were visited at home by trained health worker
Region Project Districts
Expected target
neonates (i.e. 80%
of expected
deliveries)
Number of
babies visited
by health
worker
% of babies visited
% of gap
closed =[B-
A]*100/[100-
A]
2013 2014 2013 2014 2013
(A)
2014
(B)
Nort
her
n
Bole 2147 2210 805 866 37.5 39.2 2.7
Gushiegu 3879 3992 1681 1856 43.3 46.5 5.6
Kpandai 3794 3904 438 778 11.5 19.9 9.5
Saboba 2291 2357 520 1516 22.7 64.3 53.8
Savelugu-Nanton 4856 4997 1256 1795 25.9 35.9 13.6
Tolon-Kumbungu 3699 3699 410 654 11.1 17.7 7.4
Yendi 4123 4243 2231 1928 54.1 45.4 -18.9
Total All seven districts 24790 25402 7341 9393 29.6 37.0 10.5
Upper
Eas
t
Bawku Municipal 3193 3231 1204 1067 37.7 33.0 -7.5
Bolga Municipal 4363 4415 1657 2005 38.0 45.4 12.0
Kasena Nankana East 3646 3690 888 1102 24.4 29.9 7.3
Bawku West 3119 3156 2003 2533 64.2 80.3 44.8
Garu Tempane 4312 4363 3940 4064 91.4 93.1 20.4
Kasena Nankana West § 2344 2372 - 1379 - 58.1 -
Nabdam § 1136 1284 - 832 - 64.8 -
Talensi § 2679 2711 - 1511 - 55.7 -
Total All seven districts 24791 25223 9692 14493 39.1 57.5 30.2
Source: Home-based Postnatal Newborn Care Report, 2013-2014
§ Started reporting January 2014
Focus group discussions with beneficiaries who were mothers selected from rural communities of the
Northern and Upper East regions reported significant positive behavioral change towards newborn
care among the population as a consequence of home-visits and education by nurses and volunteers,
and supportive communication activities of the intervention. Most of them reported that the days of
children with many diseases are now behind them. They expressed hope in the future of their babies
and wished that the home visits would continue. The following are illustrative statements by mothers
during the FGDs:
32
Participants in the Northern Region also reported that the health and wellbeing of their babies had
improved and their children were no longer as sick as they were in the past, thus affording them time
to go to the market to sell their wares and do business, or perform farming activities to support their
families instead of worrying, or having sleepless nights when their babies are sick. This expressed
happiness was shared by many of the mothers during the FGD sessions. One mother reported that
when she gave birth to a low birth weight baby, the nurse visited her at home and referred her to the
NCU where she was taught Kangaroo mother care, exclusive breastfeeding and other general newborn
care practices. Today the baby has put on weight and is doing well. The quote below reinforces the
perceived improvements in the health and wellbeing of the babies.
Beneficiaries also reported significant improvement in mothers’ health due to the intervention, which
sensitized and mobilized pregnant women to go to health facilities for antenatal care and facility
deliveries. FGD participants noted that the newborn care project is of great psychological helps to the
mothers. Since it reduces the frequency and severity of sickness in babies and children, it alleviates
the psychological and physical burden on mothers who no longer have to worry or spend sleepless
nights with their sick children as was the case in the past. These days, the babies are healthier and
mothers can stop worrying and carry out their daily economic activities. As reported by a mother
during the FGD:
“There has been major improvement in the lives of our babies. Our children are no
longer falling sick as it used to be. They are no longer dying or getting sick or having
skin diseases or eye diseases. We now go to the clinic to give birth.”
(FGD participant Upper East region)
“There have been changes. Hygiene practice is really helping since our children
are no longer having diarrhea and cholera as in the past. We were taught first
aid for fever in child. Putting this into practice has reduced convulsions in
children when they have fever. Now it is far better than what it used to be.
Children are no longer dying as we used to see. Immunization is also helping to
have fewer deaths”.
(FGD participant Upper East region)
“It is better now than before when many pregnant women were delivering at home.
These days more women are delivering in health facilities and we no more see mothers
dying when giving birth, even breach delivery is taking place in facility without
complication and both mother and babies are being saved”.
(FGD participant Upper East region)
33
The project considered the equity approach to programming to some extent because project
interventions were targeted at poor and disadvantaged regions with relatively high maternal
and newborn mortality.
A review of the project proposal indicated that due considerations were given to changes in the burden
of neonatal deaths during the selection of the project regions. It also indicated that the regions were
chosen to consolidate the gains recorded following a series of interventions in the past
However, if the newborn care project in the Northern and Upper East regions has to ensure full equity,
it would necessitate heavy infrastructure, human resource distribution, transport and equipment
investments. For optimal results in a resource-constrained country, it is critical to prioritize activities
and focus on the worse performing areas in order to accelerate the bridging of the inequality gap.
A national key informant attested the following on equity considerations in programming.
The national newborn strategy provides the framework for priority newborn activities, which
can be operationalized through annual plans and budgets with the support of health partners.
A review of the Medium Term Health Expenditure Plan for 2014-2017 and the Ghana Shared Growth
and Development Agenda for 2014-2017 showed that many activities can directly and indirectly
impact the lives of the newborns. The National Newborn Strategy provides a more focused framework
on newborn survival, which can be operationalized through annual plans and budgets with the support
of health partners.
Eleven (11) out of 14 national decision-makers were of the opinion that newborn issues have been
given priority attention in the national and sector policy documents (Figure 4.10) but three (3) of them
gave no opinion or disagreed.
“Sometimes we need to concentrate our efforts into just very few places. For example,
in just Greater Accra or Central region where facilities are better, but need equitable
distribution of equipment and human resources. Then we look at the data that we have,
if many neonatal deaths are occurring in the Central region then it becomes our priority.
This means that we target problem areas where the burden is, concentrate our efforts in
those areas where help is needed and build up capacity without neglecting the other
areas”.
(National key informant)
34
Objective 2: To ascertain the project’s contribution to the capacity building, developing training
resources and facility structures to respond to the high levels of newborn morbidity and mortality in
selected districts of the Northern and Upper East regions;
The project supported capacity building workshops for all district directors of health services
and public health nurses in the project districts on essential newborn care. They are now able
to plan for newborn care activities. A review of the districts’ annual plans showed that they have
all featured newborn care activities. Key informants reported that the project trained sub-
national personnel as trainers who in turn trained sub-district and community health service
providers on newborn care.
The project succeeded in putting government in the driving seat for newborn care and contributed to
build the capacity of providers to deliver quality service.
All the district directors of health services and district public health nurses in the project districts
reported to have been introduced to, or fully trained in newborn care. 26 out of 27 sub-national
decision-makers agreed or fully agreed that the project actually enhanced their capacity to plan and
prioritize newborn health services (Figure 4.3). One of them, however, had no opinion about this
statement.
35
The project succeeded in creating a national and sub-national training capacity, which could be used
for in-school basic training of nurses and midwives. The development of the community-training
module for community-based agents, volunteers and nurses was fast-tracked as a result of the project
being implemented in the Northern and Upper East regions as mentioned by one of the national key
informant below:
“Coming back to development of tools, we had started long ago working on the
community module to train community-based workers, volunteers as well as
community health officers but it was left there in a draft form. When the NBC project
started the demand was high so that we had to go back and pick that draft document
and get funding to refine the draft and finalize it for use in training community workers
and volunteers of the project areas. Now it is printed and in use elsewhere and will be
used nationwide to implement the newborn strategy”.
(National key informant)
36
Photo 2: Some training materials on essential newborn care
Key informants in the Upper East who underwent the training strongly stated that it had built their
capacity for service provision. They also indicated that the bottleneck analysis tool helped identify
the root causes of neonatal deaths as a first step in the planning process. They reported that in the past
when they did not meet their targets, they just assumed that it was due to in- or out-migration or
famine, and never questioned these assumptions or attempted to understand the root causes.
Another key informant in the Northern region reported that with the bottleneck analysis tool, the
bottlenecks and root causes were identified and the team developed a plan with a corresponding
budget to address the identified bottlenecks in newborn care. The plan was regional and every district
had its micro-plan. This plan or micro-plan are also tools to engage other funders in order to help the
district or region to address the bottlenecks.
37
The project supported capacity building workshops for frontline health workers on essential
newborn care. A total of 4,151 health workers plus community volunteers were trained on
essential newborn care. However, while service providers reported satisfaction with the training
content, the capacity created might diminish over time especially under high attrition situations.
The capacity of a total of 4,151 health workers including Doctors, Midwives, CHOs/CHNs as well as
volunteers and mother support group members was enhanced through training in life-saving skills
and essential newborn care (Table 4.2). They were imparted with the requisite knowledge and skills
to provide counseling, preventive and curative interventions, including referral to higher levels of
care towards accelerated reduction of neonatal deaths.
Table 4.2: Participants in facility and home-based postnatal care trainings during project
implementation from September 2011 to December 2014 (Phase 1 and Phase 2)
Types of
training
Northern Region Upper East Region
Total
Type of
participants
Project
phases
Phase 1 Phase 2 Phase 1 Phase 2
Facility
based
newborn
care
206 57 81 25 369 Doctors, midwives,
medical assistants,
nurses
Home-based
postnatal
care
246 180 98 292 816 CHOs and CHNs
plus enrolled nurses
700 0 598 450 1,748 Community
volunteers
0 0 1,200 0 1,200 Red Cross mother-
to-mother support
groups
0 0 18 0 18 Red Cross
supervisors, mother
to mother support
group facilitators
Total 1,152 237 1,995 767 4,151
Source: UNICEF Ghana-Government of Japan newborn project final report, 2013 and March 2015
27 out of 35 (77%) service providers whose views were sought during the field visit to the project
regions agreed or fully agreed that the training and mentorship component of the project responded
“The program has assisted us very well. We benefited from a number of trainings from
the management level to lower level. Through the training program, we were able to use
the bottleneck analysis to identify our challenges, their root causes and find way-out for
controlling the challenges, we did not say we have a problem, but we have a challenge
meaning that we can find ways to solve them through the system and do better”.
(Key informant in the Northern region)
38
to their capacity building needs (Figure 4.6). Six of them gave no opinion because they were not
selected for the formal training workshop. The two who disagreed, wanted more topics to be covered
by the training session.
The trainees are now ready with the requisite knowledge and skills to run newborn care units at
hospitals and provide home-based services to mothers and their newborns. The providers were very
happy to have undergone these trainings in newborn care. The statements below from providers are
an illustration.
Some providers in health centers and CHPS compounds who were interviewed indicated that there
were many things which they were not familiar with but have since been educated on during the
trainings on newborn care. These included how to:
“The training in newborn care was useful and helpful for my work. I go back to the
guidelines and protocols to manage each case and problem very well and every day. Before
the training, I knew little about newborn care and managing their sickness was difficult for
me and I use to refer them. The training has added values to my skills and knowledge and
now I am more confident to handle any case or complication”.
(Provider in the Upper East region)
“As a midwife I did not know much about newborn care and the training has equipped me
and given me confidence to do my work in newborn care. Now I have more experience
based on the guidelines and the counseling card. I feel confident to educate mothers even
though I do not understand very well the local language. I use pictures and they understand.
I have trained all my staff and they know how to manage newborn care and do it even if I
am not there”.
(Provider in the Northern region)
39
conduct home-based follow up or monitoring visits;
talk to mothers during home visits and sometimes husband, mother- and father-in-laws;
take care of the baby or examine or assess the baby and appreciate individual and
environmental hygiene;
keep the baby warm after delivery (skin to skin approach, kangaroo mother care etc.);
position the baby at breast;
care for the newborn and identify danger signs;
perform resuscitation; and
take care of the cord.
.
It would have been good to have the cost analysis of the investment in capacity building but a
robust cost-efficiency analysis is beyond the scope of this evaluation, so researchers were unable
to determine if the allocated resources were used efficiently to achieve the project objectives.
A total of 4,151 health professionals and community-based agents were trained at the cost of eight
hundred and eight thousand, three hundred fifty six (USD 808,356) US Dollars (Table 4.5) meaning
that on average, the cost of training a health professional in newborn care was approximately USD
194.73. Out of USD 1,812,187, 45% (USD 808,356) was spent on training and capacity building and
35% (USD 617,271) was spent on community and facility service delivery and demand generation.
The indirect cost of the project is USD 109,055 (6%).
Table 4.5: Financial Resource utilisation
Item description Phase 1 Phase 2 Amount in
USD
1. Enhanced facility and community capacity
including development of resource materials
346,733.00
461,623.00 808,356.00
2. Community and facility service delivery
and demand generation
394,706.00
222,565.00 617,271.00
3. Strengthened monitoring and evaluation
45,000.00
79,280.00 124,280.00
4. Technical assistance
5,238.00
142,233.00 147,471.00
5. Communications and visibility
0
5,754.00 5,754.00
6.Cross sectoral project support
39,908.00
69,147.00 109,055.00
Total expenditure for Programme
831,585.00 980,602.00 1,812,187.00
Total programmable amount 831,794.00 981,330.00 1,813,124.00
Programmable balance
209.00
728.00
937.00
Source: Programme financial utilization report
phase 1 and phase 2 received from UNICEF
40
There has been a reported improvement in quality of post-natal care by providers
Thirty-two (32) out of 35 (91%) service providers in selected facilities in the project districts agreed
or fully agreed that there has been an improvement in quality of care during post-natal period in the
health facilities targeted by the project (Figure 4.5). One provider disagreed with this statement and
two of them gave no opinion.
In terms of postnatal newborn care at the facility, the application of skills and knowledge acquired
during the newborn care trainings have helped improve the quality of postnatal care. Also,
supervision, monitoring and mentorship have helped improve the quality of service delivery by the
trained providers as it pertains to newborn care. Following are some quotes from service providers in
support of such quality improvement:
“There has been an improvement in quality of newborn care at the facility. Today due
to the training, we no longer fear or panic when there is a case of sick newborn. We
use the guidelines to manage the case. Our community encourages facility delivery
because of the quality of services provided. We have recorded less neonatal deaths for
the past 12 months”.
(Service provider in the Upper East region)
“Our facility report shows reduction in newborn deaths. Our admission report shows a
big increase in facility deliveries and more surviving babies than before. When we
identify any problem in the newborn that endanger the life of the baby we manage the
case using guidelines or we refer it to NCU. Newborn survival has improved a lot”.
(Service provider in the Northern region)
41
These statements from providers need to be taken as opinions and views to be crosschecked or
confirmed with existing statistics. In fact, to confirm their statements, providers indicated that prior
to this project, mothers hardly came back to the facility with the baby during the postnatal period.
It is only since this project started, that mothers are using more and more facilities for postnatal care.
The provider said, “We have referred few newborns to NCU and all of them came back well and
healthy”. One provider from Upper East gave her own example of improvement in quality of delivery
saying:
Another provider from the Northern region gave her example of a low birth weight baby weighing
1.5 kg. From the knowledge acquired during the training, she referred the baby to the NCU and the
mother was taught Kangaroo mother care techniques. The baby consequently put on weight and is
now back to healthy levels after discharge from the NCU.”
Some of the beneficiaries reported to have been educated on essential newborn care especially
through community durbars by community volunteers. But many of the mothers reported to
have obtained education and information from nurses and volunteers who spend time with them
during home visits.
During the FGDs mothers reported to have been reached by project communication and social
mobilization interventions like community durbars through volunteers and other community-based
agents. Many of them noted the friendly and persistent attitude of the nurses and volunteers to educate
them about home-based newborn care, and disease prevention. They expressed willingness to obtain
more education and information and have nurses and volunteers spend more time with them during
home visits. The majority of them who took part in the focus group discussions were able to recall
the main messages regarding breast-feeding, hand washing, diarrhea management, danger signs in
children and pregnant women. They confirmed that the information they received was very useful in
their daily life and that they tried to put into practice the advice received.
“After the training, I received a case of twin delivery and the mother was bleeding.
Since I was taught how to stop bleeding, I gave her oxytocin I.V and was able to stop
the bleeding. If it was before the training, I would have just referred the woman to the
district hospital.”
(Service provider in the Upper East)
“I always participate in durbars. They teach us general care of the child, general danger
signs for newborn, hygiene, what to do during pregnancy, importance of facility delivery and
postnatal care, hand washing before eating and after using toilet for both mothers and
children, exclusive breastfeeding up to 6 months, baby feeding after 6 months, bathing and
clothing the baby, Kangaroo mother care. After the durbar they give us drinks and we like
that”.
(FGD participant, Upper East region)
42
In order to make it easy for mothers to put education knowledge into practice their mother in-law and
husband were also taught newborn care good practices. The following is an illustration from a FGD
with beneficiary mothers.
Visual pictures and flip charts were easier for mothers to understand and retain the message being
transmitted. They found pictures and flipcharts helpful. However, some mothers clearly preferred the
case scenarios used in communicating the messages. In one case, the mother did not follow the
education on newborn care and her baby ended up dying, and in another, a mother put into practice
what she was thought and her baby survived. This was reported by one of the FGD mothers
“Education during home visits helped us to learn many things. It was important that when
nurses and volunteers came for home visits they insisted and met my mother-in-law and my
husband and educated them also on danger signs for the baby, care of the cord, exclusive
breastfeeding up to 6 months, how to position the baby at breast, when to immunize the baby
and that both mothers and baby should sleep under mosquito net. This has helped me to practice
and they support me and remind me what to do. My husband and in-laws are helping me to
keep the household environment clean”.
(FGD participant, Northern region)
“It was easier for us to have pictures and visual material that show how to practice and
compare sick babies and healthy babies when newborn care is provided. Our child
welfare book has at the back of its cover the danger signs for the baby we found it helpful
and we carry it with us”.
(FGD participant, Upper East region)
43
Photo 3: A Focus Group Discussion session in the Northern Region, 22nd January 2015
Objective 3: To ascertain the effectiveness of the project’s evidence-based advocacy for issues
related to newborn survival and national policy environment,
The aim of the project to improve neonatal survival is very much aligned with the national child
health policy as well as UNICEF’s global mandate to improve child survival.
A desk review of relevant policy documents showed that the objectives of the project were aligned
with the Government of Ghana’s Child Health Policy. The project is very much placed within
UNICEF’s global mandate to improve children’s health. The project is operationally aligned with
UNICEF’s significant presence in northern Ghana including a field office in Tamale with technical
and operational staff who provided close technical and monitoring support during the project. The
project is also very well aligned with the EMBRACE model articulated in the Government of Japan’s
Global Health Policy both conceptually as well as operationally. First, the project in UER and NR
aims to create linkages between facilities and community-based services through various actors at
both community and facility levels. Second, the project is well positioned within the overall
44
continuum of care for maternal, newborn and child health and leverages UNICEF’s investments for
other parts of the continuum of care which support healthy childhood such as immunizations and
prevention and treatment of the major child-killers such as malaria, diarrhea and pneumonia. .
On seeking the degree of agreement or disagreement of national stakeholders and health partners on
this issue, 12 out of 14 agreed or fully agreed that the intervention is relevant in terms of alignment
of project objectives with the national strategy and the stakeholders’ priorities and needs, and also in
terms of advocating for, and facilitating the introduction of newborn health into the national agenda
of the MNCH Programming (Figure 4.1). However, one stakeholder had no opinion and another fully
disagreed.
.
The project supported the processes leading up to the development and launch of the National
Newborn Strategy and Action Plan. Specifically, the project supported MoH/GHS to organise 3
national level stakeholder meetings on newborn health. It also supported the development of a
bottleneck analysis tool and decentralized the planning and monitoring of newborn health. As
reported by key informants, the launch was very successful, and the advocacy and
communication around it contributed to place newborn health on the national agenda
A desk-review of the project document showed that the project supported (financial and technical)
the MoH/GHS to organize workshops in Accra on newborn health issues. The aim of the meetings
was to have a common understanding of the package of maternal and neonatal health interventions
outlined in the current Child Health Policy and Strategy. The meeting took stock of the
implementation status with a focus on neonatal health. The project has also supported the
45
development of the perinatal death audit tool. It has also advocated for the Ghana Pediatric Society
to bring newborn care issues into the national agenda. In order to implement the National Newborn
Care Strategy, all 10 regions are now provided with a newborn health focal person.
On seeking the opinion from national decision-makers and health partners, 11 out of 14 agreed or
fully agreed that the project has contributed to the policy direction of the National Newborn Strategy
and Action Plan (Figure 4.2). However three national key informants had no opinion about this
statement.
National Key Informant interviews substantiate the remarkable efforts undertaken by GHS with
support from UNICEF and funding from the Government of Japan, in the use of evidence-based
interventions on newborn and child healthcare in the Northern and Upper East regions. GHS have
built the capacities of primary, secondary and tertiary level healthcare providers in implementing
newborn care activities. Testimonies from stakeholders, providers and beneficiaries were packaged
and videotaped by the communication section of the MOH and used effectively to advocate for
newborn health through media, and during important fora to bring newborn health high on the national
agenda. The launching ceremony was attended by high profile stakeholders, donors and a pool of
national media. There is, however, still room for additional visibility for the newborn health program
in order to mobilize necessary resources to scale it up to a nationwide level and have it on a regional
African agenda. The following are quotes from national key informants in support to the impact of
the advocacy generated by the project.
46
“I think that we have moved far, there is still room for improvement but we have come very
far because 4 or 5 years ago we did not have much to talk about newborn. Now we have a
newborn strategy. It was actually the Ministry of health and partners who recommended a
newborn strategy and Ghana Health Service was tasked to have it developed. We now have
the newborn indicators for performance monitoring. Now when we attend Ghana Health
Service meetings of directors, Ministry of health, everybody is talking about newborn”.
(National key informant)
“The national newborn strategy was launched in July last year and that launch was a very
big one. The advocacy and communication around it, was such that it went very far. We had
parliamentarians, civil society, embassy representatives, some key media personnel and
representatives from other sectors. Newborn became the talk of the town, Last year for
example almost all the professional association groups, we call them medical
superintendents, adopted a newborn theme for their annual general meeting. It was a very
busy year for us; everybody wants us to come and speak on newborn at their general annual
meeting”.
(National key informant)
47
Photo 1: Evidence of Advocacy for newborn during the launch of the newborn strategy by Minister
of Health
Furthermore, the Newborn Care (NBC) project – through its advocacy efforts – influenced the
implementation of the newborn care strategy and the insertion of NBC indicators into the DHIMS2.
Training packages, guidelines and protocols were developed to help implement the NBC strategy.
There was an advocacy effort to keep newborn care upfront on the agenda of a number of health
summits and various in-country regional and national meetings. One national key informant clearly
stated, in the quote below, the important role UNICEF played in the advocacy campaign:
“I think in 2012, there was enlightened awareness and advocacy for newborn because we
have not been able to significantly reduce newborn mortality. There was awareness raising
and advocacy throughout the country. A national conference was held in 2012. In all the
regions various stakeholders, regional directors and public health workers met and
developed plans to implement newborn care strategy. Newborn care was on the agenda of
a various meetings, WHO and UNICEF regional meetings and meeting in West Africa.
Here UNICEF is doing a lot to try to keep newborn as part of the major health activities
in the country”.
(National key informant)
48
Another key informant reported that there were lots of broad consultations before the project took off
and also while the project was running. Following broad consultations, the government was at the
table with other stakeholders to discuss issues of newborn care. The project succeeded in putting the
government in the driving seat for newborn care. The advocacy efforts of UNICEF brought together
many national stakeholders to participate in a meeting in Senegal where participating countries
reviewed the draft global newborn action plan as illustrated in the quote below:
Going down to the project districts, metallic signboards were erected at facilities and
Government of Japan stickers affixed on equipment and supplies as well as doorways to NCU
(See Photo 5).
Opinions sought from key national decision-makers showed 11 out of 14 agreed or fully agreed that
the project gave due importance on the government of Japan’s visibility (Figure 4.14) but three (3) of
them gave no opinion. They indicated that they have seen signboards of the Government of Japan at
NCU.
“I just remember a meeting we attended in Senegal concerning the newborn where
UNICEF came back to the Ghana newborn working group. From there everything was
about reviewing a global action plan for newborn which other countries were to adopt.
Working together stakeholders formed working groups of all players in the newborn and
child health space and I would say UNICEF played a very significant role in making it
happen”.
(National key informant)
49
Photo 5: Evidence of visibility of Government of Japan’s contribution
Objective 4: To draw lessons on the implementation capacity for national scale-up of the essential
newborn care model through home-based early postnatal care.
The Newborn Sub-Committee coordinates newborn care activities of all partners involved in
implementing newborn interventions. Each region and district has a focal person for newborn
care. The training modules have been adopted and are being rollout to other regions and the
home visits are being integrated into the CHPS structure.
50
A national newborn care coordinator was appointed at GHS. In each of the two regions where the
newborn care project is implemented, a regional newborn care coordinator and a district newborn
care coordinator were also appointed for each district. This arrangement enhanced linkages between
national, regional and local level professionals and facilitated knowledge and experience sharing
about the project. At the national level there is a Newborn Sub-Committee chaired by the National
Child health coordinator of GHS, who ensures coordination of the newborn care activities across all
partners involved in implementing the newborn strategy. The development and launch of the national
strategy for newborn care was another indication of ownership and leadership in promoting newborn
care. The GHS led in the development of the newborn care training modules in collaboration with
UNICEF and other development partners. These are national documents intended for rollout to other
parts of the country
Eleven (11) out of 14 national decision-makers agreed or fully agreed that Policy makers at MoH/GHS
demonstrated ownership over the different interventions related to newborn survival (Figure 4.9).
However three (3) of them gave no opinion.
Key national decision-makers expressed various opinions demonstrating their commitment to and
ownership of newborn survival interventions. As part of the advocacy for NBC, a scorecard for
reproductive maternal and newborn health was developed as requested by the African Heads of State
with a few newborn and maternal health indicators for monitoring purposes and more commitment to
newborn health. This also came out of one of the national key informants expressed in the quote
below.
51
Newborn health, and especially neonatal mortality should be considered in its proper perspective.
That is, as something which is beyond the health sector because other factors such as roads and
transport, finance, local government budgeting and commitment also affect it. Yet every time, as is
the case with most health issues, the health sector alone bears the entire burden. It is necessary for
GHS to take it up and make it a multi-sectorial issue as is now the case for HIV/AIDS. In support to
such an idea, a key national informant had this to say:
The views of key informants were that it was important to move things to a stage where newborn care
is not taken as something new or exceptional (a UNICEF or Japan’s initiative), but as a routine
standard of care. It is crucial for the government to ensure that all the health training schools or
institutions which are currently producing nurses, midwives, doctors and community health nurses,
future providers receive basic training in newborn care. When these professionals come out of school,
they should have the basic knowledge and skills needed to sustain the newborn care program. This
could ensure ownership and sustainability. On the issue of ownership by the government, a national
key informant said:
“We have developed a scorecard for reproductive maternal and newborn health,
which was a requirement from 49 Heads of State of Africa. In that scorecard, we
have a few newborn and maternal health indicators and it is our hope that our
President and Ministers will own this scorecard, as we heard it is happening in
other countries. Because as they look at it, it becomes clear to them the
bottlenecks and hopefully that will lead to more commitment to newborn care”.
(National key informant)
“I had the opportunity of making a presentation to Members of Parliament and I
showed the other sector relevant issues for newborn care, even the negative cultural
practices causing neonatal and child deaths. For the first time many of them
acknowledged that they had never thought about that before and promised to
contribute in resolving the issues”.
(National key informant)
“As it is the case for newborn care, if we were to have behavioral change we need a
sustained effort at communication and at advocacy and that has been one area that
government has committed very little funds to and whatever we get from partners is
not enough. Newborn care has a lot to do with practices at home and community
practices, the traditional beliefs and practices that need to be changed and government
seems to be ready to finance it.”
(National key informant)
52
The DHMT/DA is supportive to newborn care but is yet to demonstrate ownership to
consolidate the achievements and the expansion of the newborn health interventions within
available or mobilized resources for the district. Its resources are not sufficient to be able to self-
support the needs for a long-term sustained newborn care intervention. Challenges remain for
adequate resource mobilization for such ownership.
Most (17 out of 27) of the sub-national authorities interviewed agreed or fully agreed that the
DHMT/DAs demonstrated ownership to consolidate the achievements and the expansion of the
newborn health interventions (Table 4.11) They however, indicated that the DHMT currently does not
have the financial capacity for scale-up if funding wanes. There is also the need to design a
performance-based incentive package for community-based volunteers for the sustainability of the
home-based care. Ten (10) of them gave no opinion or disagreed.
Key informant in the Upper East region reported that in terms of demonstrating ownership, the
District Assembly (DA) is doing many things with their own limited resources to improve newborn
care. For instance, they are constructing CHPS compound, supporting the training of some senior
staff members to expand access and coverage of health interventions. This is what appears in the
quote below from a key informant:
“District Assembly is expected to mobilize internally generated funds to support health
activities. But the people are so poor; they cannot generate anything, Market resources’ are
so negligible and therefore a really difficult situation for them. But they all show commitment,
because when you look in their development plan, health is one of their major concerns in
terms of building infrastructure. Some Assemblies are supporting training for medical Doctors
for maternal and child health including the newborn”.
(Key informant in the Upper East region)
53
In the Northern region, especially in Savelugu, the maternity ward was newly built in 2013 by support
of the Government of Ghana and the project provided NCU equipment. The Tamale municipal
assembly is financing some renovations for its health center.
Some key informants strongly believe that even if UNCEF is no longer financing newborn care
activities in the Upper East region, the activities will continue because the skills are there and people
will continue to work, the only problem is the staff movement and the need to build capacity of new
staffs with more training sessions and more NCU equipment. One of them said, “We just need to
move to routine services that will require limited resources to ensure community-based newborn care
services by volunteers with bicycles”. For sustainability one key informant has proposed:
In Northern region the proposed solution by key informants was to build extra capacity in those areas
where providers have not been able to reach. This would mean training hundred volunteers or more,
and possibly bearing the cost of an extra two hundred in anticipation of ownership and sustainability.
This is indicated in the quote below:
However, there are challenges in terms of available resources to finance home visits, maintenance of
the NCU and staff retention. There is an urgent need for resolving problems that prevent adequate
functioning of the NCU (oxygen cylinder, baby warmer, fluids etc.), and effective regular home visits
in some CHPS zones or health centers (motorbike and its maintenance). Staff shortage and attrition
is also a challenge to ensure smooth running of the facilities.
Government resources to the sector are limited and basically for the regions, where the health services
depend on the internally generated funds mainly from the national health insurance scheme.
Unfortunately, the delay in payment by the insurance scheme is further threatening service provision.
In some instances it was difficult to finance home visits due to the lack of fuel for the motorbikes.
One key informant presented the situation as follows:
“Services would be a routine that will not require extra resources. It will be good to have
civil society and goodwill person support the program and provide some bicycles or fuel
just for the volunteers to move within the community and see the newborn and the mother.
GHS will possibility give soaps to volunteers as motivation. This is what we wish could be
done for sustainability, but we are not there yet”.
(Key informant in the Upper East region)
“Once all staffs are trained and we use the local engineer who is helping us very well, I
think we will be able to own this newborn care program and we think we can do
everything possible to sustain such project”.
(Key informant in the Northern region)
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Hence, the main challenge is the availability of motorbikes to visit mothers in the community. For
some time now, most of the motorbikes supplied to CHO/CHN for outreach and home visits are not
in working condition. These motorbikes were supplied by the government and UNICEF some time
ago and they are now broken down. It is expected that UNICEF or other donors will step forward to
improve the situation.
Service providers did admit that despite the success of the project there exist some bottlenecks, which
need to be addressed. These include: infrequent home visits by nurses due to lack of motorbikes or
breakdown of their own motorbike which they use as a substitute, insufficient personnel due to staff
attrition or trained nurses going back to school for further training, lack of means of transportation
for supportive supervision or performance monitoring, and volunteer fatigue due to the absence of
incentives.
This is what participants in one of the FGDs suggested addressing these bottlenecks:
The enhanced commitment and motivation of CHOs can last for a continued provision of home-
based services if the high morale and enthusiasm of applying new skills and supportive
supervision can be maintained, and if the challenges around fuel and motorbike supply are
resolved.
When opinions of service providers in selected health centres and CHPS compounds whose staff were
trained in newborn care were sought, 33 out of 35 agreed or fully agreed that they remain committed
to the home-based services to newborns (Figure 4.12).
“From the government, we expect staff to visit at least seven homes in the day to be able to see
all newborns and their mothers. But when the fuel is not there, or the motorbike broke down,
we are not able to do this. Some of us have been using our own motorbikes for home visiting,
but when the fuel is not coming regularly then it becomes another issue”.
(Key informant in the Upper East region)
“Provide support to our facility to facilitate referral to hospital, which is far away.
Expand the facility for more space and recruit more nurses and volunteers for home
visits. Provide motorbikes for nurses to conduct more home visits. Give incentives to
volunteers (rain coats and robber boots) to allow them to do home visits during rainy
season and visit the far to reach areas.”
(FGD participant, Upper East region)
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A review of some district annual reports, for example Bole District, showed that trained staff attrition
has been high especially among the CHOs/CHNs (Table 4.5) who are the key drivers of the home-
based newborn care. These staff that had training in newborn care have either been reposted to other
districts or gone on study leave. Until the district managers commit to institutionalize periodic training
in newborn care and pre-service is strengthened for all CHNs and CHOs (new and old) this situation
has a potential threat to the sustainability of the home-based services.
Table 4.5: Number of trained Health Professionals at post, Bole district
Category of Staff # Trained Attrition % attrition
Nurse Manager 1 0 0.0
Medical Assistants 5 1 20.0
Midwives 7 2 28.6
Staff Nurses 1 0 0.0
CHOs/CHNs 48 25 52.1
Enrolled Nurses 10 0 0.0
Total 72 28 38.9
Source: Bole district annual report, 2014
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The good news is that those currently posted exhibited high morale and the enthusiasm with regards
to the application of new skills, supportive supervision and better relationships with mothers who
showed gratitude for saving their babies. However in the long run, motivation might deteriorate
especially if basic needs such as the supply of basic newborn care equipment, the renovation of the
facilities to allow more space for service delivery, and the introduction of financial and nonfinancial
motivation schemes (especially for midwives, CHOs/CHNs) are not provided.
Providers demonstrated high motivation and commitment to conduct home visits to mothers. In the
Upper East region, they reported that there was at times no fuel for home visits or there was a delay
in obtaining it. The motorbikes provided by the Ghana Health Service were no longer functional and
had not been replaced. This posed a challenge for regular home visits. In addition some providers face
language barriers while communicating with mothers and had to use unpaid volunteers as interpreters.
They also had no raincoats, an item which could facilitate home visits during the rainy season. The
available space for providing facility care was very small and the same room was used for delivery,
counseling and hospitalization of mothers who had just delivered babies. All these provided highly
demotivating conditions for the providers to carry out their work and home visits. The good news is
that when asked, they indicated that they remained motivated for their work. The quote below is an
evidence of such motivation and commitment.
Providers also reported that the type of bag provided by UNICEF is difficult to handle and manipulate
in the field. A bag that could be hung on the back would be more comfortable. Some major equipment
for newborn care such as oxygen cylinders were lacking everywhere. Some innovation might be
needed to ensure that the facility delivery trend is maintained.
The behavioral changes among beneficiaries on essential newborn care can be sustained if the
newborn care projects approach to influence beneficiary behavior through home-based
education by nurses and volunteers and communication for development activities are
maintained and sustained.
The newborn care project’s approach to influence beneficiary behavior through home-based
education by nurses and volunteers proved to be effective in delivering correct information
concerning when and where to go when a newborn or a child is sick or has danger sign. The mothers
in the FGD indicated that they have found the information on caring for their babies very useful and
that they will continue to practice it. Therefore, efforts in sustaining the gains in communication for
development activities are critical for the mothers to maintain the practice.
“We have only one motorbike for the facility to conduct outreach for immunization and home
visits. I do not have a personal motorbike. I take taxi for home visits and taxi people charge me
a lot. But, I like the work and try to do home visits whenever possible. Because of high staff
attrition after their training in newborn care, we have no midwife and even though I am a nurse,
I do the deliveries myself, antenatal and postnatal care, and home visits”.
(Provider in the Northern region)
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The FGD with beneficiaries revealed that the right information might not reach the right person.
Culturally, the family structure foresees a strong role for mothers-in-law as main family decision
makers on issues pertaining to child bearing, feeding and treatment. However, mothers-in-law are
usually not direct targets of communication and awareness intervention. The findings of the FGDs
suggested that direct targeting of this group would be beneficial for newborn care.
In the Northern region, beneficiaries reported to be very happy about the work of nurses and
volunteers and it should continue. They acknowledge that some of the negative behavior in the past
has changed. Mothers reported during FGDs that today, hand-washing for the kids before eating and
after using toilet is in practice and personal and environment hygiene practices are duly observed.
They also reported that in the past, there were many cord infections due to cultural practices such as
putting various products (local herb or traditional medicine) on the cord. This behaviour has changed
with the teaching mothers, in-laws and husbands how to care for the cord. Mothers reported to be
happy with the changes and expressed their wish for the program to continue.
It should be noted that as reported by one beneficiary, some mothers are not available to meet with
nurses and volunteers when they visit due to their economic activities or other obligations that enable
them to generate money to pay school fees for their children. These women see the visits from the
nurses and volunteers as a burden, especially when no prior appointment has been arranged.
Thankfully this is a rare occurrence. One beneficiary said:
In the Upper East, beneficiaries reported that their babies are healthier and that they now practice
exclusive breastfeeding, maintain a clean environment and observe sound hygiene practices. They
reported cultural practices were not easy to change due to their mothers-in-law who needed to approve
the new practices that were taught before they could be implemented. Thanks to their persistent visits,
volunteers and nurses were able to convince mothers-in-law on the mothers’ behalves to allow the
implementation of these new practices. This is illustrated in the quote below.
“Now the community better understands the care of the cord. Just to clean it and do not
put anything on the cord. Taking care of the newborn is a collaborative responsibility which
brings husband and mother in-laws to be supportive to the wife”.
(FGD participant, Upper East region)
“This behaviour has changed with the teaching of how to care for the cord to mothers,
in-laws and husband. Mothers reported to be happy with the changes and would like
the program to continue”.
(FGD participant, Northern region)
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Beneficiaries in the Upper East region reported behavioral changes that can be sustained. They believe
the project is helping them have healthy babies. Thanks to the project, children are better and mothers
now have time to conduct the economic activities required to support the family instead of worrying
when their babies are sick. According to them, the community now better understands how to care
for the cord. Education on the use of mosquito net has also helped reduce malaria cases.
The project facilitated synergies and avoided duplications of interventions and strategies
promoted by other UN agencies and development partners through partner forums, national
newborn sub-committee and MAF implementing committee meetings.
In countries where there are multiple partners it is important to create such fora to avoid the
duplication of projects in one district and to leverage others’ resources for optimum results or
synergies.
In-depth interview with UN agencies, development partners and national decision-makers revealed
that partners do have a forum where they meet quarterly to share information on on-going and planned
projects. The National Newborn Sub-committee also provides the platform for health partners to
discuss and share further information on newborn activity. There is also a MAF implementation
committee that meets quarterly to discuss progress and the current commitment of partners.
When opinions were sought, 5 out of 7 national decision-makers and partners agreed or fully agreed
that the project facilitated synergies and avoided duplications (Figure 4.13) but one of them disagreed
and another gave no opinion. The questionnaire, however, did not ask for reason for such
disagreement.
“When the visitors came they met my mother in law and educated her on exclusive
breast feeding, care of the cord, danger signs, child welfare and the importance of
immunization, eye diseases and skin diseases and that both mothers and baby should
sleep under mosquito net. They understood and complied with it and we can see the
changes”.
(FGD participant, Upper East region)
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UNICEF, with funding from the Japanese government, started the NBC project in the Northern and
Upper East regions. Today, JICA is implementing the NBC in the Upper West. The USAID-funded
University Research Corporation (URC) for Systems for Health Project is to be implemented in 5
other regions namely: the Volta, Northern, Central, Western and Greater Accra regions. PATH is also
implemented in the following 4 regions: Brong Ahafo, Ashanti, Eastern and Volta regions. This
coordination has helped ensure synergy and avoided duplication.
Ghana Health Service now has a newborn care secretariat to coordinate the activities of its various
health partners’. The secretariat will streamline the partners’ requests and make sure that there is
minimal duplication in the same area for NBC. However, partners sometimes have their own plan
which governs their funding allocations – thus forcing beneficiaries to either take it or leave it. It is
very difficult to decline a partner’s money. This is a challenge and the secretariat often needs to further
discuss issues and come to an agreement with the partner in question. One way of handling such
situation has been proposed by a key informant.
The project incorporated the HRBA to programming in accordance with UNICEF’s global
mission. Children’s rights were paid attention to in the project’s design – especially the right of
newborns to survive and have a good quality of life.
The general view of the national key informants was that the project considered in its design “the
Convention on the Rights of the Child” which forms part of UNICEF’s global mission.
Nonetheless, the rights of the child should be reflective of the child’s life beyond the mere
considerations implemented during the project’s design. Key informants reported that newborns’
rights go as far as giving maternity leave to working mothers in order to afford her time to breastfeed
the baby, and offering her a space at work so she can continue breastfeeding the baby. Below is a
quote:
:
“We need a good coordinating secretariat, because just like HIV coordination bodies. In
some countries, you have partners from different institutions treating HIV patients
differently, but in Ghana that does not happen. With the NACP and the Ghana Aids
Commission you cannot just come in and start anything anyhow. Ghana Health Service
should have a strong coordination council for newborn health”.
(National key informant)
“The newborn right goes beyond the newborn. It is a big issue especially with working mothers
who are breastfeeding and the duration of maternity leave. The work places should have space
that could allow mothers to breastfeed their babies on demand. It is a very big human right for
the baby because we are denying the baby to receive mother’s care”.
(National key informant)
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The use of community structures such as community-based volunteers as well as the home visits
by CHOs/CHNs has helped to bring MNCH services to the doorstep of mothers and babies.
Twelve (12) out of 14 national decision-makers/partners expressed the view that the project, by
training staff on newborn care and equipping all health centres and district hospitals with newborn
care equipment has removed geographical barriers that limited access to newborn care. The home-
based care and the community mobilization components has also been recognized to facilitate the
reduction of access barriers to newborn services at the community level (Figure 4.17). Two
participants, however, expressed no opinions.
A national key informant has a solution, we quote:
“Because of bad roads, long distance, difficult to reach areas and insufficient human resources,
ensuring access to MNCH across the country is a big challenge. Possible solution is that District
Assembly or partners could sponsor training of CHO/CHN or midwives so that they will remain
within the district after training for 5 years under an agreement to provide health services and
conduct home visits to mothers. Donors could also help construct waiting homes or rooms for high
risk pregnancies so that during the last month the woman can stay there, close to a health facility
for delivery”.
(National key informant)
.
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5. Lessons learned
From this evaluation we can derive the following lessons that could be used in future design,
implementation of the next phase of the project and other relevant interventions. These lessons will
help to be more effective in implementing other newborn projects.
1. Using the community structures (CHOs/CHNs, community volunteers, mother support groups)
improved timely home-based care and helped foster provider-community partnership.
2. Immediate follow up has helped to avert the newborns from negative cultural practices (such as
applying herbs to the cord which has potential for infection)
3. Fathers’ involvement in the home-based visits had contributed to improve acceptance of
practices on care of the newborn.
4. Periodic training of Midwives and CHOs improved their knowledge and skills and gave them
confidence to deliver quality care.
5. The establishment of the newborn care units (NCU) created demand for newborn care and saved
the lives of many preterm and low birth-weight babies.
6. Conclusions and Recommendations
6.1 Conclusions
The home-based postnatal newborn care and neonatal intensive care models have been effective in
contributing to improved newborn survival in the two project regions of Upper East and Northern
regions of Ghana, to the extent possible given the scope and reach of the intervention. The enhanced
capacity of NCUs, with essential newborn care equipment as well as the enhanced capacity of health
personnel in terms of skills acquired for management of sick and preterm babies, have been important
enabling factors for saving the lives of many babies in the project districts. The evidence-based
advocacy efforts at all levels have contributed significantly to making newborn issues a national
priority especially culminating into the development and launch of a National Newborn Strategy and
Action Plan.
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6.2 Recommendations
The challenge for improving newborn health lies in ending preventable newborn deaths and securing
Ghana’s future. Success will be measured in terms of lives saved and lives improved. Success will
depend on meeting the needs of women and their babies throughout the continuum of care and
committing to the following action items:
National Level:
1. The Government should commit enough resources to operationalize the National Newborn
Strategy and Action Plan. The Newborn strategy could be used as a framework for donor
support. Donor assistance should be mapped onto strategy priorities and Donor projects have
to be coordinated to achieve strategy objectives. A system should be in place for effective
monitoring and assessment of achievements and resource management tools should be in
place to ensure accountability. A national budget line for newborn activities needs be
envisioned. An advocacy group may be put in place to ensure continued resource mobilization
for Newborn Strategy implementation.
2. The MoH/GHS should ensure that every district hospital has Newborn Care Unit for
secondary level 2 care. All regional and teaching hospitals should have Newborn Intensive
care Units (NICU) for tertiary level 3 care. Health Centers and Polyclinics where delivery is
conducted should have provision of Basic Emergency Obstetric and Newborn Care
(BEmONC) including Newborn Care Corner (NCC).
3. The GHS/MoH should establish resource centres in Regional and Teaching Hospitals along
with NICU, to the extent possible using existing structures, to facilitate on job training on
newborn care. Staff from the resource centres should deliver a transferable skills program
through mentorship and periodic specialists’ visits to lower level facilities.
4. The GHS should scale-up the home-based postnatal newborn care model to all districts in the
regions and to other regions. The evaluators do not anticipate any delay if national and sub-
national decision-makers commit to this course. The materials have already been developed
and lessons learned can speed up nationwide scale-up. GHS could take advantage of the fact
that in all ten regions there is ongoing newborn activities in some of the districts supported by
various donors such as UNICEF (2 regions), USAID HSS (5 regions), USAID JHPIEGO (4
regions), PATH (4 regions), JICA (1 regions) and KOICA (1 region). This will require
coordination and harmonization on a minimum package of effective newborn care
interventions for the reduction of newborn mortality.
5. The MoH should review curriculum of the Midwifery and Community Health Training
Schools to include issues on newborn care or update and strengthen any existing such training
program using the newborn care training modules, which were developed in collaboration
with UNICEF and other development partners and which have now been accepted as national
documents intended for nationwide roll-out. The MoH and GHS should collaborate to
formulate and approve detailed implementation plan and budget for integration of the newborn
care training package into the pre-service, postgraduate and continuous education systems.
The in-service training should also be reinforced for those already in the field.
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Sub-national (region and district) level:
6. The District Directors should collaborate with the District Assemblies (DA) to ensure that
newborn care issues become a standard agenda on district quarterly review meetings. This
implies advocacy work using neonatal mortality data from the district statistics as to inform
the DA on the urgency of mobilizing funds to address newborn care issues as a priority in the
district. The DA should have a local budget line for newborn care as a sustainable financing
solution for both maternal and newborn care services within the district. This will help the
district address a number of challenges related to newborn care activities such as incentive
and motivation for volunteers and CHO/CHN, fuel and maintenance for motorbikes used for
home visits, bicycles for volunteers. The financial contribution of the district to newborn care
activities will encourage MoH/GHS to supplement with recruitment of additional Human
resources in shortage (nurses, midwives and pediatrician) and provide needed equipment such
as new motorbikes for facilities and materials for NCU.
7. Regions and districts could have in place a community performance-based financing scheme
with performance reward approach where community volunteers, providers and sub-district
team will be given money for anticipated performance. An agreement will be established with
each district and group of providers to implement newborn care activities with well-
established results and coverage for which funds will be provided and financial incentives
provided based on performance and percentage of expected results achieved. This will be an
option for better coverage and achievements with newborn care.
8. Institutionalization of perinatal death audit and newborn death audit would be fundamental to
ensure increased attention to newborn care and the causes and circumstances of neonatal death
in order to address them more effectively and reduce neonatal mortality. It will also help avoid
neonatal deaths due to poor performance or mistakes or inappropriate action of the providers.
To prevent those unnecessary neonatal deaths, Regional Health Management Teams, Hospitals
and the MoH/GHS should integrate newborn care indicators to the existing M&E system to
monitor performance, progress, facility neonatal deaths and achievements in newborn care by
providers and volunteers. This could be reinforced with provision of newborn care registers
for hospital, facilities and community visits. Regions and district health managers should be
encouraged to use effectively these newborn indicators and newborn death audit results in
planning and implementation of health service decisions as well as in assessing staff
performance.
9. Regional and district leadership should be strengthened to drive newborn agenda and provide
support for implementation. The District Directors should be tasked to develop a
comprehensive plan with costing for capacity building and refresher training schedule for staff
involved in newborn care. They must maintain register of staff and track staff movement to
manage any capacity gap arising in order to reduce staff attrition. Further steps should be taken
to provide the necessary conditions to retain trained service providers at the deprived
communities. Part of the available resources should be used for incentive and motivation of
volunteers and CHO/CHN to do more home visits. Regional and District Leadership should
reinforce the home-based postnatal care as part of routine activity and demand accountability
64
from the CHOs/ CHNs by periodically assessing their home visit register. Number of
newborns visited at home at day 3 and day 7 within 0-7 days following birth should be
included in the performance appraisal of the CHOs and CHNs.
Cross Sectoral Support:
10. Quality Assurance (QA), Quality Improvement (QI) and access to quality newborn care
services is important for attainment of the MDGs. MoH/GHS is already putting in place
QA/QI system for health service delivery. This should be extended to newborn care services
at all levels including facility level with providers and community level with volunteers. There
should be an external and internal newborn care quality audit system. Proposed system will
improve evidence-based managerial decision-making at facility and local levels and will
increase the competition and staff motivation to better perform. It should provide needed
supportive supervision and mentorship to improve quality of the newborn care services
offered by the health providers.
11. National and subnational levels should support effective documentation, communication and
advocacy activities for newborn care. They should develop a communication strategy for
newborn care and its implementation plan with costing. Further steps should be taken to
document newborn stories in the field (what is happening? what is new?) then record them
and use media to disseminate them. With support from local community members they should
document bad perceptions towards newborns especially neonates, negative sociocultural
practices and address them with behavioral communication, education of mothers, husbands,
in-laws and families during home visits and social/community mobilization. They should
intensify health education involving community members, opinion leaders, traditional and
religious leaders to recognize the importance of the care of the newborn and the mothers for
their greater survival. They should consolidate the gains in C4D activities on newborn care
using community volunteers. This will require the involvement of the District Assemblies for
a small motivation of the volunteers actively involved in C4D to ensure that they could
continue the home-based newborn care activities with mothers, community participation and
demand generation for newborn care.
12. National and subnational levels should support secondary data analysis to identify barriers to
newborn care and address them and use operation research results for more evidence on the
table to support funds mobilization and advocacy for newborn care. Steps should be taken to
address the issue of gender and ensure greater male involvement. Human rights based
approach and equity should be part of the sub-national implementation of newborn care
activities. They should put in place a system that will contribute to sustainability of newborn
care activities and use quality improvement method at facility level with rewards to regions,
districts and selected providers that are improving in newborn care.
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References
1. UN Inter-agency Group for Child Mortality Estimation I: Levels and trends in child mortality:
Report 2013. New York: UNICEF, 2013. (http://www.childinfo.org/%1Fles/Child_Mortality_Report_2013.pdf, accessed 12 June 2014).
2. Darmstadt GL, Kinney MV, Chopra M, et al. for The Lancet Every Newborn Study Group,. : Who has been caring for the baby? . Lancet 2014, published online 19 May 2014.
http://dx.doi.org/10.1016/S0140-6736(14)60458-X. 3. Ghana Statistical Service"GSS", 2011: Ghana Multiple Indicator Cluster Survey with an
Enhanced Malaria Module and Biomarker Final Report. Accra, Ghana, 2011.
4. Ministry of Health/Ghana Health Service GoG: National Assessment for Emergency Obstetric and Newborn Care. . Accra, Ghana 2011.
5. UNICEF, WHO, 2014 : Every Newborn: An Action Plan To End Preventable Deaths; 30 JUNE 2014. Johannesburg, South Africa.
6. Ministry of Health, Government of Ghana, United Nations Country Team in the Republic of Ghana,
2011: Ghana MDG Acceleration Framework And Country Action Plan Maternal Health. Jul 1, 2011
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Appendices
AP1. Informed Consent Form
Formative evaluation of the project entitled “Accelerating efforts to reduce
maternal, neonatal and child mortality in the Northern and Upper East regions”
INFORMED CONSENT FORM
Thank you for agreeing to participate in this Evaluation.
The purpose of this formative evaluation is to understand whether the intended objectives of the
newborn care project implemented in Northern and Upper East regions of Ghana have been achieved.
Specifically, the evaluation will determine to what extent the intervention has been able to meet its
objective to create capacity, tools and structures to respond to the high levels of newborn morbidity
and mortality in the two-targeted regions.
The project partners– MoH and GHS, UNICEF, and JICA – will use the findings of the evaluation in
their different capacities and functions, to develop future plans and interventions and to inform
policies and strategies.
The methods that will be used to meet this purpose include face-to-face semi-structured interview and
focus group discussions with selected key informants.
You are encouraged to ask questions or raise concerns at any time about the nature of the evaluation
or the methods to be used.
Please contact me at any time at the e-mail address ([email protected]) or telephone number (+233-
244-280-495).
Our discussion will be audio taped to help me accurately capture your insights in your own words.
The tapes will only be heard by me for the purpose of this evaluation. If you feel uncomfortable with
the recorder, you may ask that it be turned off at any time.
You also have the right to withdraw from the evaluation at any time. In the event you choose to
withdraw from the evaluation all information you provide (including tapes) will be destroyed and
omitted from the final paper.
Insights gathered by you and other participants will be used in writing an evaluation report, which
will be disseminated. Though direct quotes from you may be used in the paper, your name and other
identifying information will be kept anonymous.
By signing this consent form I certify that I ___________________________ was informed and has
agree to participate in this evaluation (Print full name here).
____________________________ ______________
(Signature) (Date)
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AP2. Evaluation tools (In-depth interview guides, Short questionnaires, FGD guide)
AP2a0: General Background Data
1. Introduction to the objectives of the evaluation
To ascertain the effectiveness of the package of evidence-based maternal, neonatal and
child survival interventions with a focus on community-based (Home based Postnatal Care)
and facility based (IMNCH) approaches in the selected districts of the Northern and Upper
East Region;
To ascertain the project’s contribution for the capacity building, developing training
resources and facility structures to respond to the high levels of newborn morbidity and
mortality in selected districts of the Northern and Upper East Region;
To ascertain the effectiveness of the evidence-based advocacy of the project on the national
policy environment on the issues related to newborn survival;
To draw lessons on the implementation capacity for national scale-up of the essential
newborn care model through home-based early postnatal care;
2. General information
a. First Name and Surname: ________________________________________
b. Title and post/position: ________________________________________
c. Institution /Organization _+_____________________________________
d. Government _____Civil society____ Donor ____ Partner _____Other _____
e. Sex F _______ M _________
f. Age_______________________________________
g. Place of interview: ____________________________________________
h. Date of interview: (DD_______ MM _________ YYYY___2015____
68
i. Time of interview: Beginning________________ End _____________
j. Interview order number____________________________________
AP2a1: Interview Guide for Key National Decision-Makers/Stakeholders
1. Introduction to the objectives of the evaluation
To ascertain the effectiveness of the package of evidence-based maternal, neonatal and child
survival interventions with a focus on community-based (Home based Postnatal Care) and
facility based (IMNCH) approaches in the selected districts of the Northern and Upper East
Region;
To ascertain the project’s contribution for the capacity building, developing training
resources and facility structures to respond to the high levels of newborn morbidity and
mortality in selected districts of the Northern and Upper East Region;
To ascertain the effectiveness of the evidence-based advocacy of the project on the national
policy environment on the issues related to newborn survival;
To draw lessons on the implementation capacity for national scale-up of the essential
newborn care model through home-based early postnatal care;
2. A brief introduction to the semi-structured interview
Be assured that this interview is confidential and what you say will be used only for the
purposes of this evaluation but anonymously;
Please do not hesitate if you wish withdraw at any time
3. General information (See separate page)
4. Interview order number_________________________________
5. Introduction to the topic under review:
We are here to evaluate the newborn care project of GHS / UNICEF / Government of Japan
in Northern and Upper East regions of Ghana
6. Permission to proceed and to record the discussion
7. Questions:
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Relevance:
R1: Is the intervention relevant in terms of alignment of project objectives with national strategy and
stakeholder’s priority and needs?
Effectiveness:
E1: To what extent has the project contributed to the policy direction of the National Newborn
Strategy and Action Plan?
Efficiency:
Eff1: Were the allocated resources used efficiently to achieve the project objectives? Are the available
resources adequate to meet project needs?
Sustainability:
S1: To what extent does policy makers at MoH/GHS demonstrated ownership over the different
interventions related to newborn survival?
S2: To what extent has the Government of Ghana prioritized the health and wellbeing of newborn
babies in the government’s policy documents (Ghana Shared Growth and Development Agenda for
2014-2017, Medium Term Health Expenditure Plan for 2014-2017) and allocation of resources
(budget line on approved Ministry of Health budget) for newborn health?
Coherence: C1: To what extent does the project facilitated synergies and avoided duplications with interventions
and strategies promoted by other UN agencies and development partners (JICA, USAID, EC, PATH
and others) within the National Child Health Policy 2007-2015 and MDG5 Acceleration Framework
(MAF)?
C2: To what extent has the project given due importance on donor’s (Government of Japan) visibility
in line with UNICEF’s donor visibility guidelines;
Human right based approach (HRBA):
H1: To what extent does the project incorporated the Human right-based approach to programming?
H2: To what extent does the project consider the equity approach (i.e. focus on most deprived areas,
areas with high prevalence of critical newborn and under-5 mortality, low income families) and
facilitate the reduction of access barriers to MNCH services by the target group?
8. Do you have any suggestion for improvement of newborn health care?
9. Ask if s(he) would like to add further comments.
10. Bring the meeting to a close by summarizing the main points.
11. Thank the key informant
12. Write the time
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AP2a2: Short Questionnaire for Key National Decision-Makers / Stakeholders
Introduction: We are conducting a formative evaluation of the above-mentioned project. We would
appreciate your contribution to this evaluation.
PART A: Please indicate to which group you belong:
/_ / Ministry of Health / Government of Ghana
/_ / Ghana Health Service
/_ / UNICEF or Other partner involved in project funding or implementation
/_ / Donor Partner
/_ / International Organization
/_ / NGO or Civil society
/_ / University or Academia
/_ / UNICEF staff
/_ / Other (please specify) ______________________________
PART B: Please indicate your degree of agreement or disagreement with each of the following
statements on a scale from 1 to 5
5 : Fully agree
4 : Agree
3 : No opinion
2 : Disagree
1 : Fully disagree
1) R1: The intervention was relevant in terms of alignment of project objectives with national strategy
and stakeholder’s priority and needs.
1 2 3 4 5
2) E1: The GHS/UNICEF/Government of Japan project contributed to the policy direction for the
national newborn health strategy and action plan
1 2 3 4 5
3) Eff1a: The allocated resources were used efficiently to achieve the project objectives.
1 2 3 4 5
4) Eff1b: The available resources were adequate to meet project needs.
1 2 3 4 5
71
5) S1: The policy makers at MoH/GHS demonstrated ownership over the different interventions
related to newborn survival.
1 2 3 4 5
6) S2: The Government of Ghana prioritizes the health and wellbeing of newborn babies in the
government’s policy documents (Ghana Shared Growth and Development Agenda for 2014-2017,
Medium Term Health Expenditure Plan for 2014-2017) and allocation of resources (budget line on
approved Ministry of Health budget) for newborn health.
1 2 3 4 5
7) C1: The GHS/ UNICEF/Government of Japan project facilitated synergies and avoided
duplications with interventions and strategies promoted by other UN agencies and development
partners (JICA, USAID, EC, PATH and others) within the National Child Health Policy 2007-2015
and MDG5 Acceleration Framework (MAF).
1 2 3 4 5
8) C2: The GHS/UNICEF/Government of Japan project gave due importance on donor’s
(Government of Japan) visibility in line with UNICEF’s donor visibility guidelines.
1 2 3 4 5
9) H2b: The project facilitated the reduction of access barriers to MNCH services by the final
beneficiaries.
-
1 2 3 4 5
PART C: Please answer the following questions with your own opinion.
12) What are the two major contributions of the newborn care project by UNICEF to Ghana health
agenda?
a)__________________________________________________________
b) _________________________________________________________
13) In future how do you see the newborn project evolve? What does it take to get there?
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
72
AP2b1: Interview Guide for Key Sub-National Decision-Makers
13. Introduction to the objectives of the evaluation
To ascertain the effectiveness of the package of evidence-based maternal, neonatal and child
survival interventions with a focus on community-based (Home based Postnatal Care) and
facility based (IMNCH) approaches in the selected districts of the Northern and Upper East
Region;
To ascertain the project’s contribution for the capacity building, developing training
resources and facility structures to respond to the high levels of newborn morbidity and
mortality in selected districts of the Northern and Upper East Region;
To ascertain the effectiveness of the evidence-based advocacy of the project on the national
policy environment on the issues related to newborn survival;
To draw lessons on the implementation capacity for national scale-up of the essential
newborn care model through home-based early postnatal care;
14. A brief introduction to the semi-structured interview
Be assured that this interview is confidential and what you say will be used only for the
purposes of this evaluation but anonymously;
Please do not hesitate if you wish withdraw at any time
15. General information (See separate page)
16. Interview order number_________________________________
17. Introduction to the topic under review:
We are here to evaluate the newborn care project of GHS / UNICEF / Government of Japan
in Northern and Upper East regions of Ghana
18. Permission to proceed and to record the discussion
19. Questions:
Effectiveness
E2: To what extent has the project contributed to strengthen capacity of regional health management
teams and district health management teams for planning, informed decision making and
prioritization of the newborn health as per the National Child Health Policy (2007-2015) and other
national guidelines and protocols?
Sustainability
S1: To what extent do RCC/GHS, District Assembly/DHMT demonstrate ownership and capacity
for resource mobilization to be able to self-support and consolidate the achievements and the
expansion of newborn health interventions?
73
20. Do you have any suggestion for improvement of newborn health care?
21. Would you like to add further comments?
22. Bring the meeting to a close by summarizing the main points.
23. Thank the key informant
24. Write the time
AP2b2: Short Questionnaire for Key Sub-National Decision-Makers
Introduction: We are conducting a formative evaluation of the above mentioned project. We would
appreciate your contribution to this evaluation.
PART A: Please indicate to which group you belong to
/_ / Ghana Health Service Regional level
/_ / Ghana Health Service District level
/_ / UNICEF Other partner involved in project implementation
/_ / International organization
/_ / NGO or Civil society
/_ / UNICEF staff
/_ / Other (please specify) ______________________________
PART B: Please indicate your degree of agreement or disagreement with each of the following
statements on a scale from 1 to 5
5 : Fully agree
4 : Agree
3 : No opinion
2 : Disagree
1 : Fully disagree
1) E2: The GHS/UNICEF/Government of Japan project has contributed to strengthen capacity of
regional health management teams and district health management teams for planning, informed
decision making and prioritization of the newborn health as per the National Child Health Policy
(2007-2015) and other national guidelines and protocols.
1 2 3 4 5
2) S1: The DHMT and District Assembly demonstrated ownership and capacity for resource
mobilization to be able to self-support and consolidate the achievements and the expansion of
newborn health interventions.
1 2 3 4 5
74
PART C: Please answer the following questions with your own opinion.
3) What are the two major contributions of the newborn care project by UNICEF to Ghana health
agenda?
a)__________________________________________________________
b) _________________________________________________________
4) In future how do you see the newborn project evolve? What does it take to get there?
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
AP 2c1: Interview Guide For Service Providers
(Obstetricians, Pediatricians, Neonatologists, Nurses, Midwives, Patronage Nurses, GPs)
25. Introduction to the objectives of the evaluation
To ascertain the effectiveness of the package of evidence-based maternal, neonatal and child
survival interventions with a focus on community-based (Home based Postnatal Care) and
facility based (IMNCH) approaches in the selected districts of the Northern and Upper East
Region;
To ascertain the project’s contribution for the capacity building, developing training
resources and facility structures to respond to the high levels of newborn morbidity and
mortality in selected districts of the Northern and Upper East Region;
To ascertain the effectiveness of the evidence-based advocacy of the project on the national
policy environment on the issues related to newborn survival;
To draw lessons on the implementation capacity for national scale-up of the essential
newborn care model through home-based early postnatal care;
75
26. A brief introduction to the semi-structured interview
Be assured that this interview is confidential and what you say will be used only for the
purposes of this evaluation but anonymously;
Please do not hesitate if you wish withdraw at any time
27. General information (See separate page)
28. Interview order number_________________________________
29. Introduction to the topic under review:
We are here to evaluate the newborn care project of UNICEF / Government of Japan in
Northern and Upper East regions of Ghana
30. Permission to proceed and to record the discussion
31. Questions:
Which training package did you attend?
Effectiveness
32. Are training contents (including protocols and guidelines) suitable for the Ghanaian
Northern and Upper East regions newborn care delivery system? Why?
33. Was this training pertinent to your current daily work? Why?
34. Before attending the training, did you feel the need to upgrade your knowledge and skills?
Why? In which field/s?
35. Do patients appreciate the improvement in newborn care in your health facility? Why do
you say this?
36. Since you started applying the acquired skills, is there any noticeable improvement in
newborn care for the mothers who deliver in your health facility? Why do you say this?
37. Do you feel that the training enabled you to fully apply, in your daily practice, what you have
learnt? Why?
38. How often do you apply the acquired skills and knowledge into work practice?
39. Were you reluctant to accept new practices/procedures (reluctant to change)? Which ones?
Why?
40. Did the acquired knowledge and skills affect (could be both, positively and negatively) your
self-confidence and the value you put on your daily work? Why?
41. What is the significance, if any, of providing newborn care?
76
42. Is there a facilitative supervision and monitoring system in place? Is this system able to
support you to apply acquired skills, and reliable information and data for decision makers?
Why? Please describe. What is your involvement in the monitoring process?
43. To what extent has there been an improvement in quality of care during delivery and post-
natal care in the health facilities targeted by the project?
44. To what extent was the training and mentorship component of the project responding to
capacity building needs of the different levels of service providers?
45. Is the training package relevant to your needs for better performance?
46. Can you describe the visit by a supervisor for newborn care practice, when, duration and
process of the supervision?
47. What kinds of topics were covered during the training sessions? What happened after the
training?
Sustainability
48. At the work place, are there some conditions that prevent you to correctly practice your skills?
(i.e. non-confident in skills despite training, shortage/lack of basic equipment/amenities,
drugs, time constraints, referral etc.). Please, describe.
49. Are you receiving any incentive/did you expect to be incentivized/awarded for delivering
quality MNCH services? Please, describe.
50. Do you have any suggestion for improvement of newborn health care?
51. Would you like to add further comments?
52. Bring the meeting to a close by summarizing the main points.
53. Thank the key informant
54. Write the time
77
AP 2c2: Short Questionnaire For Service Providers
Introduction: We are conducting a formative evaluation of the above-mentioned project. We would
appreciate your contribution to this evaluation.
PART A: Please indicate to which group you belong
/_ / Ghana Health Services Regional level
/_ / Ghana Health Services District level
/_ / Health facility (Health centre/CHPS)
/_ / UNICEF or Other partner involved in project implementation
/_ / International organization
/_ / NGO or Civil society
/_ / Other (please specify) ______________________________
PART B: Please indicate your degree of agreement or disagreement with each of the following
statements on a scale from 1 to 5
5 : Fully agree
4 : Agree
3 : No opinion
2 : Disagree
1 : Fully disagree
1) E3a: The established level-two (without ventilator and incubators) newborn care units in six
District Hospitals have improved the management and survival of sick newborn babies.
1 2 3 4 5
2) E4: There has been an improvement in quality of care during delivery and post-natal care in the
health facilities targeted by the project.
1 2 3 4 5
3) E5: The training and mentorship component of the project responded to capacity building needs
of the different levels of service providers.
1 2 3 4 5
4) S4a: The enhanced commitment and motivation of CHO/CHN and community volunteers (CBAs)
will last, for a continued provision of home-based services to mothers and their newborn babies.
1 2 3 4 5
78
PART C: Please answer the following questions with your own opinion.
5) What are the two major contributions of the newborn care project by UNICEF to Ghana health
agenda?
a)__________________________________________________________
b) _________________________________________________________
6) In future how do you see the newborn project evolve? What does it take to get there?
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
AP2d: FGD Guide For Beneficiaries
1. Introduction to the objectives of the research
2. A brief introduction to the rules of focus groups
a. Everything said and done is confidential and will not be used outside the room except for the
purposes of this evaluation;
b. Every statement is right;
c. Please do not hesitate to disagree with someone else;
d. Please do not all talk at once
3. Ask people to describe who they are and say few words about themselves
4. Introduce the topic under review - We are here to evaluate the Newborn care project and its home
based visits and get your opinions and appreciations
5. Ask for permission to proceed and to record the discussion
6. Ask questions
Effectiveness
Is the communication package relevant to your demands and needs?
Can you describe the visit by a nurse or a health agent, when, duration and process of the visit and
topics of counseling if you received it?
79
What kind of topics did nurse or community agent covers during communication on children’s
care: provide information? or /and show examples or/and give you an example for practice?
What is the primary form of communication that makes you to understand the message?
a. Flip chart on key child feeding, caring and health seeking practices? b. mother
card?
c. posters?
d .examples?
e. practice?
f. Other, please specify?
How often do you apply acquired skills and knowledge into practice?
Did you/ or other family members receive adequate information on newborn or child care?
And who provided this information?
How long it takes the counseling on newborn or child care? Do you think that duration of
the counseling and the content is sufficient?
Did you receive any information or sensitization project communication or social
mobilization interventions, like community durbars, mother support groups, community
based agents and Red Cross mothers (in Upper East Region)?
Did you see an improvement in your newborn care and health seeking practices (ANC,
PNC, well baby clinic) as a consequence of improved counseling by CHO/CHN, CBA,
Red Cross mothers and mother support groups?
How much have the intervention contributed to improve health and wellbeing of newborn
babies and their mothers and in terms of changing health seeking behavior?
What kind of information do you want or need to receive as a mother/caregiver on
newborn or child care?
What are the ways you would like to receive that information?
What was the content and form of information you have received so far on newborn or
child care?
Was the content of materials easy to understand and practical?
Sustainability
What changes did you noticed in people’s behavior for essential newborn care? How do
you see these changes continue in future? What do you see as bottlenecks or barriers that
hinder the capacity of mothers and caregivers to access and use quality newborn care
services for them and their babies?
To what extent is the commitment and motivation of CHO/CHN and community
volunteers (CBAs) that was enhanced through the project perceived to last, for a continued
provision of home-based services to mothers and their newborn babies?
80
7. Do you have any suggestion for improvement in newborn care?
8. Ask if they would like to add further comments.
9. Bring the meeting to a close by summarizing the main points.
10. Thank you!
81
AP3. Evaluation Framework
Criteria Questions/Levels Indicators (where
appropriate)
Sources of data Methods
Relevance:
R1 R1: National decision-making
Is the intervention relevant in terms
of alignment of project objectives
with national strategy and
stakeholder’s priority and needs and
also in terms of advocating for and
facilitating to bring the newborn
health into the national agenda of
MNCH Programming?
Degree of congruence
between project strategy
and stakeholders priority
and needs
Documents: Government
of Ghana Newborn care
policy; National Child
Health Policy, Project
documents; UNICEF's
newborn care strategy
documents; Government of
Japan's MNCH strategy
documents
Key Informants:
GHS Family Health
Division; MoH/GHS
PPME, Donor Partners,
(See Appendix AP4)
Desk review
Semi-
Structured
Interviews/In-
depth
interviews
Effectiveness
E1 E1: National decision-making
To what extent has the project
contributed to the policy direction
of the National Newborn Strategy
and Action Plan in terms of
advocating for and facilitating to
bring the newborn health into the
national agenda of MNCH
Programming?
Advocacy campaign;
National newborn strategy
and Action Plan
developed and launched
MoH policy documents;
Project monitoring reports
Key Informants:
GHS, Family Health
Division; MoH/GHS
PPME (See Appendix
AP4)
Desk review
Semi-
Structured
Interviews/In-
depth
interviews
E2 E2: Sub-national decision-making
To what extent has the project
contributed to strengthen capacity
of regional health management
teams and district health
management teams for planning,
informed decision making and
prioritization of the newborn health
as per the National Child Health
Policy (2007-2015) and other
national guidelines and protocols?
Number of
Regional/district health
management teams
trained in newborn care;
Proportion of district
action plans that have
newborn care activity;
Documents:
Regional/District Health
Action Plans
Key Informants:
Regional/District Directors
of Health Services
Desk review
Semi-
Structured
Interviews/In-
depth
interviews
E3 E3: Service providers
(a) To what extent is the established
level-two (without ventilator and
incubators) newborn care units in
six District Hospitals improved the
management and survival of sick
newborn babies?
(b) Which are the enabling/
constraining factors that facilitated/
hindered the management of sick
newborn babies in District
Hospitals?
Neonatal deaths per 1,000
live births;
Neonatal deaths per total
admission into NCU.
% of kangaroo mother
care; % of sepsis
management
DHIMS; District annual
and activity report;
Facility data from two
NCUs
Key Informants:
Services Providers
Extraction of
data from
district annual
report
Semi-
Structured
Interviews/In-
depth
interviews
82
E4 E4: Service providers To what extent has there been an
improvement in quality of care
during post-natal care in the health
facilities targeted by the project?
DHIMS (2)
Key Informants:
Services Providers
Extraction of
data from
DHIMS
Semi-
Structured
Interviews/In-
depth
interviews
E5
E5: Service providers:
To what extent has the training and
mentorship component of the
project responded to capacity
building needs of the different
levels of service providers?
Number of health
professionals (Nurse,
Midwife, CHN/CHO)
trained in life-saving
skills and essential
newborn care
Documents
Project monitoring reports;
Training modules and
materials;
Key Informants
Health professionals
trained in newborn care
Desk Review
Semi-
Structured
Interviews/In-
depth
interviews
E6 E6: Final beneficiaries’ level:
To what extent do beneficiaries
report to have been reached by
project communication and social
mobilization interventions, like
community durbars, mother support
groups, community based agents
and Red Cross mothers (in Upper
East Region)?
Number of visits, social
mobilisation events,
durbars
Document: Project
monitoring report, District
annual and activity report
Beneficiaries
Mothers in project
communities
Desk review
Data extraction
from Project
monitoring
report
FGD
E7 E7: Final beneficiaries’ level:
To what extent do beneficiaries
report an improvement in their
newborn care and health seeking
practices (ANC, PNC, well baby
clinic) as a consequence of
improved counseling by
CHO/CHN, CBA, Red Cross
mothers and mother support
groups?
Percentage of low birth
weight babies on
kangaroo mother care;
Percentage of
mother/infant pairs
exclusively breastfeeding
at discharge.
Project review report;
DHIMS (2)
Beneficiaries
Mothers in project
communities
Extraction of
data
FGD
E8 E8: Final beneficiaries
To what extent do the intervention
contributed to improve health and
wellbeing of newborn babies?
Percentage of babies
visited at home by trained
health worker
DHIMS (2)/ District
annual and activity report
Beneficiaries: Mothers in
project communities
Extraction from
DHIMS/
District record
FGD
83
Efficiency:
Eff1 Eff1: National
(a)Were the allocated resources used
efficiently to achieve the project
objectives?
(b) Are the available resources
adequate to meet project needs?
Some measure of
productivity: Service
output per estimated cost
of the intervention
package (=Service
output/total cost)
Project monitoring report;
District annual and activity
report; DHIMS (2)
Key Informants:
Donor Partners
Extraction of
Cost of project
from Project
monitoring
report; and
service output
from
DHIMS (2).
Semi-structured
interviews/In-
depth interview
Sustainability:
S1 S1: National
Have policy makers at MoH/GHS
demonstrated ownership over the
different interventions related to
newborn survival?
Evidence of dedicated
officer for newborn care
at all levels
Documents: National
Policy documents on
newborn care.
Key informants: DG,
GHS Family health
division
Desk review
Semi structured
interview/In-
depth interview
S2 S2: National
Has the Government of Ghana
prioritized the health and wellbeing
of newborn babies in the
government’s policy documents
(Ghana Shared Growth and
Development Agenda for 2014-
2017, Medium Term Health
Expenditure Plan for 2014-2017)
and allocation of resources (budget
line on approved Ministry of Health
budget) for newborn health?
Evidence of newborn
issues in government
policy documents. Budget
line for newborn in
approved MoH budget.
Amount allocated as a
percentage for the total
budget for newborn care
(GHS)
National Policy documents
on newborn care and
MoH/GHS budget
Key informants: DG,
MoH-PPME, GHS Family
health division
Desk review
Semi structured
interview/In-
depth interview
S3 S3: Sub-national decision-making
Have DHMT and District Assembly
demonstrated ownership and
capacity for resource mobilization
to be able to self-support and
consolidate the achievements and
the expansion of newborn health
interventions?
Evidence of dedicated
officer for newborn care;
Proportion of MMDA
budget dedicated to
MNCH activity.
Documents:
Project activity reports.
Project monitoring
database. Newborn care
budget forecasts. Sub-
national newborn care
budgets.
Key Informants:
Regional/District Health
Managers; District
Assembly
Desk review
Semi-
Structured
Interviews/ In-
depth interview
S4 S4: Service providers
(a) Can the commitment and
motivation of CHO/CHN and
community volunteers (CBAs) that
was enhanced through the project
last, for a continued provision of
home-based services to mothers and
their newborn babies?
(b) What are the bottlenecks and
barriers for the home-based
postnatal care within the framework
of continuum of MNCH care?
Proportion of trained
health professionals (HP)
at post;
Documents
Districts annual reports;
Key Informants: Trained
HPs
Extraction from
district annual
reports
Semi-
Structured
Interviews/ In-
depth interview
84
S5 S5: Final beneficiaries
Can the behavioral changes among
beneficiaries on essential newborn
care be sustained?
Key informant: Mothers
in project communities
FGD
Coherence:
C1 C1: National
Has the project facilitated synergies
and avoided duplications with
interventions and strategies
promoted by other UN agencies and
development partners (JICA,
USAID, EC, PATH and others)
within the National Child Health
Policy 2007-2015 and MDG5
Acceleration Framework (MAF)?
Evidence of an
established system
supporting coordination
among UN agencies and
development partners
Key Informants:
DG, GHS family health
division, Donor Partners,
UNICEF Project Staff
(See Appendix AP4)
Semi-
Structured
Interviews/ In-
depth
interviews
C2 C2: National
Has the project given due
importance on donor’s (Government
of Japan) visibility in line with
UNICEF’s donor visibility
guidelines.
Evidence of donor’s
visibility in the project
districts
Project districts/NCU
Key Informants:
DG, GHS family health
division, Donor Partners,
UNICEF Project Staff (See
Appendix AP4)
Take photos of
signboards,
equipment, and
supplies with
Government of
Japan stickers
affixed on.
Semi-
Structured
Interviews/ In-
depth
interviews
Human right
based
approach
(HRBA):
H1 H1: National
Has the project incorporated the
HRBA to programming?
Program documents spells
out HRBA elements Documents
The conversion of the right
of the child (i.e. the
standard),
Planning and general
project documents.
Desk review
(review project
document
against the
standard)
H2 H2: National
(a) Has the project considered the
equity approach (i.e. focus on most
deprived areas, areas with high
prevalence of critical newborn and
under-5 mortality, low income
families)
(b) Has the project facilitated the
reduction of access barriers to
MNCH services by final
beneficiaries?
Justification/Criteria for
selecting project regions.
Home-based newborn
postnatal services – PNC
for newborn (48 hours)
Project document
Key Informants:
DG, GHS family health
division, Donor Partners,
UNICEF Project Staff (See
Appendix AP4)
Desk review
Semi-structured
interviews/ In-
depth
interviews
85
AP4. List of National Decision-Makers/Stakeholders Interviewed No. Participants
Name
Designation Organization Email Address Contact Remarks Area of
Discussion
5. Dr. Isabella
Sagoe-Moses
GHS National
Child Health
Coordinator,
GHS
[email protected] 024 464
6065
Interview
and
Inception
Meeting
Overall project
6. Dr. Patrick
Aboagye
Director Family
Health
Division,
GHS
[email protected] 024 328
3327
Interview
and
Inception
Meeting
Overall project/
MAF
7. Gloria
Quansah-
Asare
Deputy
Director
General
Ghana Health
Service
[email protected] 024 373
3541
Interview
and
Inception
Meeting
Overall project
8. Dr. Agongo
PPME
Director, PPME Programme
Planning,
Monitoring
and
Evaluation,
GHS
[email protected] 024 429
3835
Interview Policy Planning
Issues
9. Dr, George
Amofah
Retired, Deputy
Director
General, GHS
[email protected] 024 432
2843
Interview National
newborn
strategy
development/
general PH
issues
10. Dr. Odame PPME Ministry of
Health
[email protected] 020 886
8792
Inception
Meeting
Interview
on NNS and
MAF
11. Dr. Lorna
Renner
Pediatrician Paedieatric
Society of
Ghana
[email protected] 020 824
3945
Bigger
picture chat
12. Dr Linda
Vanotoo
Grater Accra
Regional
Director
Ghana Health
Service
[email protected] Inception
Meeting
Interview
Perinatal audit
13. Sodzi Sodzi
Tettey
Project Five
Alive
Project
Director
[email protected] 020 630
1109
Inception
Meeting
Interview
Quality of Care
14. Dr. Cynthia
Bannerman/
Deputy
Director
Institutional
Care
Directorate,
Ghana Health
Service
[email protected] 0302662014 Inception
Meeting
Interview
15. Christina
Akuffo
Nurse Quality A GHS [email protected] 023 306
6615
057 842
1237
Quality
Assurance
16. Itsuko
Shirotani
JICA [email protected] 0244871042 Inception
Meeting
Interview
Donor
perspective
17. Salamatu
Futa
USAID [email protected] 0244247903 Inception
Meeting
Interview
Donor
perspective
86
18. Vandana USAID Inception
Meeting
Interview
Donor
perspective
19. Dr. Divine
Atpura and
Alex Nazar
USAID System
for Health
[email protected] 0244760
799
Inception
Meeting
Interview
Health System
20. Chantelle
Allen/Team
Joyce
ablorrdeppey
Jhpiego [email protected] 0545410970 Inception
Meeting
Interview
Training/quality
of care
21. Patience
Cofie
PATH [email protected] 0242681272 Inception
Meeting
Interview
22. Jannet Mortoo EC Programme
Officer EC
Bigger
picture
chat- MAF
MAF support
from EC
23. Esi Amoaful GHS Director
Nutrition
Division
Inception
Meeting
Interview
24. Dr Robert
Mensah
UNFPA Bigger
picture
chat- MAF
UNICEF Cross Sectoral/Accra
21 David WASH Wash in
Health
Facility
22 Lilian and
Gloria
Nutrition Chat Breast
Feeding –
Discussion
23 Anna Maria/
Clemens
M&E Anna is
team of
evaluation
24 Philomena/
Peter
LEAP 1000 UNICEF LEAP 100
Chat
25 Emelia Allen Child
Protection
Birth
Registration
26 Surangani/
Charity
C4D Chat on
C4D
27 Monica and
Evelyn
Baddoo
Communication Visibility
UNICEF/Tamale
28 Ms. Felicia
Mahama, Dr.
Imran
H&N Interview
87
AP5a. Evaluators’ work schedule.
Table 3.2 Work schedule
Date Time Activity Venue
2 January 2015 9am – 12 noon Arrival of International Consultant Accra
5th January 11am-12.15pm Internal Meeting with UNICEF Team UNICEF House
6th January 11am- 1pm Inception meeting with National
Newborn Sub-Committee
UNICEF House
7th – 9th January 8am-4pm each day Bilateral meetings with Key National
decision makers and health partners for
in-depth interviews
Accra
13th – 14th January Travel to Tamale (Northern region) by
road with a sleep over in Kumasi.
Introductory meeting with UNICEF
Tamale Team.
Meeting with Regional Director, GHS,
Tamale
Travel to Bolga (Upper East Region)
Tamale
Bolga
14th to 19th January am/pm Field visit Upper East Region
19th January Afternoon/evening Return to Tamale
20th – 28th January am/pm Field visit Northern Region
28th January Morning Return to Accra
28th – 4th February Data analysis, report writing and
presentation
Meetings with partners
Submission of draft Evaluation
report
UNICEF House
5th February National Debriefing Meeting UNICEF House
7th February Departure from Accra (International
Consultant)
AP5b. Percentage change in institutional neonatal deaths by districts in the two regions
Table 4.1: Percentage change in institutional neonatal deaths per 1,000 live
births over the period 2012-2014 in the project districts
Region/Districts 2012 2014 % change
Northern 6.9 3.4 -50.7
Bole 7.6 6.7 -11.8
Gushiegu 1.8 0.59 -67.2
Kpandai 3.1 1.8 -41.9
Saboba 0.7 1 42.9
Savelugu-Nanton 1.4 0 -100.0
Tolon 1.5 0 -100.0
88
AP6. Terms of Reference (Attached)
Kumbungu 1.3 0 -100.0
Yendi 2.2 0 -100.0
Upper East 5.8 3.3 -43.1
Bawku 12 4.1 -65.8
Bawku West 4.7 0.83 -82.3
Bolgatanga 6.9 5.3 -23.2
Kasena-Nankana 17.2 13.4 -22.1
Kasena-Nankana West 1.2 0 -100.0
Garu-Tempane 0 0.49
Talensi 0 0
Nabdam 1.1 0 -100.0
Source: Ghana Health Service DHIMS(2) as @ 19th Jan 2014
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