Modeling Lives Saved with EQUIST for Sub-National Investment Planning in Ghana
Throughout the last two decades, Ghana has implemented several national measures aimed at improving overall child survival and health equity in the country. [1] While these policies amplify the necessity of health equity, Ministry of Health focal points have had limited capacity to analyse health sector data prior to the introduction of the EQUitable Impact Sensitive Tool (EQUIST) in Ghana.
To determine and address national and sub-national health equity, counterparts from Ghana underwent several capacity building trainings and investment planning workshops from October to November 2018. The workshops were funded by the Global Alliance on Vaccines and Immunization (GAVI) and UNICEF. This was done in a concerted effort to better understand and use EQUIST and how the tool can promote health equity, provide for nutrition and immunization investment planning and avert health sector-related deaths.
The first of the three trainings took place from 1-5 October 2018 and participants from the Ministry of Health, the Ghana Health Service, the School of Public Health of the University of Ghana and the UNICEF Country Office (CO) came together with Community Systems Foundation (CSF) and ICF Macro technical staff to learn and utilize EQUIST.
Through the completion of equity impact scenarios on EQUIST using District Health Service (DHS) data, participants performed bottleneck analysis to identify cost-effective interventions that would provide for the highest deaths averted and to develop micro-plans and investment cases for fundraising. As a result, national health experts are now able to enhance users’ capacity at the sub-national level.
In mid-October, the Ghana CO and a team from New York University, led by Shahrouh Sharif, came together for the Nutrition Investment Planning Equity Workshop. Here, nutrition focal points discussed the necessity of focusing on vitamin A supplementation, early initiation of breastfeeding and exclusive breastfeeding, as well as therapeutic feeding for developing investment cases.
To better higher-quality analyses and to generate additional funding for health equity analysis, CSF counterparts worked with Ghana Health Service to ensure that District Health Information Management System 2 (DHIMS) data was available at the sub-national level. In doing so, validated, reliable and good quality subnational data can now be used by national counterparts to engage potential donors to invest in the most cost-effective scenarios that would provide for high-quality nutrition programmes in Ghana.
Directly following the nutrition workshop, the Ghana CO collaborated with the Ministry of Health and the Ghana Health Service to bring together national immunization experts for the Immunization Investment Planning Equity Workshop. During this training, workspaces were created on EQUIST for each region of Ghana and a workspace was also created highlighting the 91 low-performing priority districts, targeting districts with low coverage of penta 3-dose and measles-rubella 2-dose coverage (MR2) to reach Global Vaccine Action Plan (GVAP) targets.
Creating workspaces at the sub-national level enables Ghana to identify the underlying health issues, causing high rates mortality and morbidity and to create more focused health equity analyses that will lead to higher programme impact and a greater return on investment.
During the immunization workshop, participants worked collaboratively to model deaths averted and relevant costs by implementing immunization interventions and reducing bottlenecks with EQUIST. Specifically, participants focused on improving the coverage of penta3; measles-rubella 2 doses and vitamin A supplementation within the priority districts.
Focusing on priority districts helped participants contextualize bottleneck analysis and the impact that EQUIST is having and can continue to have in Ghana.
Through analysis, approximately 10,000 projected under-five deaths could have been averted through the scaling up of key immunization interventions in the 91 lowest performing districts situated across all regions of Ghana. As participants performed this analysis, they could see that an intervention similar to this would come at a cost of less than $US 0.01 per capita, making the intervention both cost-effective and highly impactful.
As one of the first countries in West Africa that is able to use sub-national data from DHIS2 for equity analysis, Ghana should be seen as a model of how countries can use EQUIST to streamline national health equity efforts, promote how the tool can help overcome bottlenecks and demonstrate how the suggested interventions can lead to overall deaths averted.
[1] These policies have included Community-based Health Planning Services (CHPS), a National Health Insurance Scheme and a free maternal and child health policy designed to address financial barriers for basic health services, especially for the most vulnerable.