Governance and the effectiveness of public health subsidies: Evidence from Ghana, Kenya and Uganda

Using the Ghana malaria indicator survey to understand the difference between female and male-headed households and their prevention and testing for malaria among children under 5

Background

Globally, 94% of malaria deaths occur in sub-Saharan Africa, and children under age 5 account for 70% of malaria-related mortality in the region. This study sought to examine differences between female-headed households (FHHs) and male-headed households (MHHs) with regard to malaria prevention and testing among children under age 5 (U5) in Ghana.

Methods

This cross-sectional study used publicly available data from the 2019 Ghana Malaria Indicator Survey (GMIS). Frequencies and descriptive statistics were calculated for all key variables. Bivariate analyses comparing FHHs and MHHs were conducted using t tests and Chi-square analysis. A P value of 0.05 was taken for statistical significance.

Results

Five thousand one hundred and eighty one household were identified, of which 1938 (37.4%) were female-headed and 3243 (62.6%) were male-headed. 51.7% of FHHs included a child U5, whereas 67.8% of MHHs included a child U5. MHHs were significantly more likely to own an ITN than FHHs (83.1% vs. 78.3%, P < 0.001), whereas FHHs were more likely to report taking malaria prevention steps such as spraying the house with insecticide, filling in stagnant puddles, and keeping surroundings clear (all significant at P < 0.001). U5 children in MHHs were more likely to sleep under a bed net the night preceding the survey (51.0%) than U5 children in FHHs (44.8%), although the finding was not statistically significant. The rates of fevers in the previous two weeks among children U5 were similar across MHH and FHH (24.2% vs. 22.3%), and the rates of testing for malaria among those who experienced a febrile episode were also similar across MHHs and FHHs (39.0% vs. 41.3%). Of those tested, the percentage of U5 children who tested positive for malaria was also similar across MHHs and FHHs (63.9% vs. 63.0%).

Conclusions

Both FHHs and MHHs in Ghana make a concerted effort to prevent and test for malaria among children U5 in their households. Despite differences in malaria prevention strategies, there were no significant difference in febrile episodes, malaria testing, and rates of positivity, suggesting that malaria prevention is challenging for all households in Ghana. In the face of a newly-developed malaria vaccine, future research is warranted to ensure adequate uptake across all households.

The impact of the private sector co-payment mechanism (PSCM) on the private market for ACT in Nigeria: results of the 2018 cross-sectional outlet and household market surveys

Background

The private sector plays a large role in malaria treatment provision in Nigeria. To improve access to, and affordability of, quality-assured artemisinin-based combination therapy (QA-ACT) within this sector, the Affordable Medicines Facility-Malaria began operations in 2010 and transitioned to a private sector co-payment mechanism (PSCM) until 2017. To assess the impact of the scheme on the ACT market, cross-sectional household and outlet surveys were conducted in 2018 to coincide with the final stockages of ACT medicines procured under the PSCM.

Methods

An outlet survey was conducted targeting private pharmacies and Proprietary and Patent Medicine Vendors (PPMVs) across different regions of Nigeria to assess supply-side market factors related to availability and cost of anti-malarials, including artemisinin-based combinations subsidised under the PSCM (called green leaf ACT on account of their green leaf logo) and those not subsidised (non-green leaf ACT). A concurrent household survey was conducted to determine demand-side factors related to treatment-seeking practices, ACT brand preference and purchase decision. Data were compared with previous ACTWatch surveys to consider change over time.

Results

Availability of artemisinin-based combinations increased significantly over the PSCM period and was almost universal by the time of the 2018 market survey. This increase was seen particularly among PPMVs. While the cost of green leaf ACT remained relatively stable over time, the cost of non-green leaf ACT reduced significantly so that by 2018 they had equivalent affordability. Unsubsidised brands were also available in different formulations and dosages, with double-strength artemisinin-based combination reported as the most frequently purchased dosage type, and child artemisinin-based combinations popular in suspension and dispersible forms (forms not subsidised by the PSCM).

Conclusions

The PSCM had a clear impact on increasing not only the reach of subsidized QA brands, but also of non-subsidised brands. Increased market competition led to innovation from unsubsidised brands and large reductions in costs to make them competitive with subsidised brands. Concerns are drawn from the large market share that non-QA brands have managed to gain as well as the continued market share of oral artemisinin monotherapies. Continued monitoring of the market is recommended, along with improved local capacity for QA-certification and monitoring.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-021-04039-9.

Climate change, women's workload in smallholder agriculture, and embodied political ecologies of undernutrition in northern Ghana

The burden of child undernutrition across Africa remains extraordinarily high. Among children under age five, chronic and acute undernutrition is responsible for more ill-health than any other cause. While climate change exacerbates the multiple burdens of undernutrition, we know very little about the embodied effects on women's workload in agriculture and implications for feeding practices, especially for infants whose nutrition depends on mothers' time. In this article, political ecologies of health, with its nested, place-based analysis, is used as a framework to address this knowledge gap. The study took place in Ghana's Upper West Region, a semi-arid and resource-poor setting with higher undernutrition rates. In-depth interviews were conducted with smallholder farmers (n = 33) whose infants have sub-optimal growth, and key informants (n = 7) with expertise in nutrition and health. Findings from the study demonstrate how climate change puts pressure on women's productive time, leading to poor child feeding practices and undernutrition. Ultimately, the article argues that there are hidden impacts of climate change on undernutrition. Global undernutrition interventions should therefore move beyond biomedical solutions to address these hidden impacts, some of which are social, gendered, and structural in nature.

Corruption in Anglophone West Africa health systems: a systematic review of its different variants and the factors that sustain them

West African countries are ranked especially low in global corruption perception indexes. The health sector is often singled out for particular concern given the role of corruption in hampering access to, and utilization of health services, representing a major barrier to progress to universal health coverage and to achieving the health-related Sustainable Development Goals. The first step in tackling corruption systematically is to understand its scale and nature. We present a systematic review of literature that explores corruption involving front-line healthcare providers, their managers and other stakeholders in health sectors in the five Anglophone West African (AWA) countries: Gambia, Ghana, Liberia, Nigeria and Sierra Leone, identifying motivators and drivers of corrupt practices and interventions that have been adopted or proposed. Boolean operators were adopted to optimize search outputs and identify relevant studies. Both grey and published literature were identified from Research Gate, Yahoo, Google Scholar, Google and PubMed, and reviewed and synthesized around key domains, with 61 publications meeting our inclusion criteria. The top five most prevalent/frequently reported corrupt practices were (1) absenteeism; (2) diversion of patients to private facilities; (3) inappropriate procurement; (4) informal payments; and (5) theft of drugs and supplies. Incentives for corrupt practices and other manifestations of corruption in the AWA health sector were also highlighted, while poor working conditions and low wages fuel malpractice. Primary research on anti-corruption strategies in health sectors in AWA remains scarce, with recommendations to curb corrupt practices often drawn from personal views and experience rather that of rigorous studies. We argue that a nuanced understanding of all types of corruption and their impacts is an important precondition to designing viable contextually appropriate anti-corruption strategies. It is a particular challenge to identify and tackle corruption in settings where formal rules are fluid or insufficiently enforced.

Managing uncertainty in medicine quality in Ghana: The cognitive and affective basis of trust in a high-risk, low-regulation context

Where regulation is weak, medicine transactions can be characterised by uncertainty over the drug quality and efficacy, with buyers shouldering the greater burden of risk in exchanges that are typically asymmetric. Drawing on in-depth interviews (N = 220) and observations of medicine transactions, plus interviews with regulators (N = 20), we explore how people in Ghana negotiate this uncertainty and come to trust a medicine enough to purchase or ingest it. We identify two mechanisms - attempts to mitigate uncertainty through seeking observable signs of quality and attempts to reduce informational asymmetry - that underpin cognitive assessments of a medicine's trustworthiness. However, these 'cognitive' forms of trust assessment have limited traction where uncertainty is high and trustworthiness remains unknowable, so a third mechanism comes into play: one based on affective relationships within which transactions are socially embedded. Even these, however, cannot eliminate uncertainty, because of the dispersed and under-regulated nature of wider supply chains. In conclusion, we reflect on the need for careful research on actors' practices and decision-making across supply chains to inform more effective policy and regulation.