Addressing the Health Needs of Children and Youth in Ghana Challenges and Prospects

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1 Addressing the Health Needs of Children and Youth in Ghana Challenges and Prospects Gloria J. Quansah Asare (BSc., M.B. Ch.B, MPH, Dr.PH) Reproductive & Child Health Unit 1, Ghana Health Service. I. Introduction Ghana adopts the WHO definitions for health, children and youth where, health is defined as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. From birth to the age of 18 years an individual is considered a child, while the youth are individuals aged between 15 to 24 years and those aged 10 to 24 years are referred to as young people. The health and developmental needs for these periods of life vary. Therefore, for programming purposes, specific groupings namely, under fives (birth to 5 years); school health (5 to 15 years); and adolescent health and development (10 to 19 years) are targeted. The target groups overlap during programming. In some instances, programmes cover groups before and beyond the target ages, and benefit or contribute to other programmes. An example is the adolescent health programme. Even though adolescence covers the period ten to nineteen years, for comprehensive programming the Adolescent Health & Development (ADHD) programme also targets preadolescents (5-9 years) and young adults (20-24 years) 1 There are strong linkages between child health and reproductive health as well as nutrition, mental health and other sectors such as Education, Women and Children s Ministry, youth and employment and others including private sector and non-governmental organizations. The health and development of a newborn depends on what happens during pregnancy which falls under the safe motherhood programme. Health Needs versus Rights Defining need is complex and depends on who is making the decision and how need is measured. The Advanced Oxford Dictionary defines need as a circumstance in which something is lacking or requires to be done. However, Culyer and Wagstaff [ 2 ] show that the need for health care can be defined in many ways: such as, severity of disease, or the ability to benefit or the minimum amount of resources required to exhaust the capacity to benefit; and goes on to demonstrate that each of these meanings affects the distribution of health services differently. Economists express health need as a burden of disease and measure it in terms of years of quality life lost. But this is based on assumptions on individual preferences which are often culture-bound. Health workers express need in terms of mortality or morbidity, but this is influenced by the type of disease and the quality of the data. Parents and political authorities also define need differently. In a study carried out in Northern Ghana, mothers and fathers expressed children s needs in terms of need for healthy foods, first aid, good water, prevention from mosquito bites, medicines and cleanliness. The Millennium 1 National Family Planning Programme Manager 1

2 Development Goals (MDGs) and the health sector usually identify health needs from morbidity and mortality perspectives and these are dependent on availability and quality of data. Thus most programmes aim at reducing morbidity and mortality A right, on the other hand, is a person s entitlement to a good, service or liberty. Thus, a rights-based approach emphasises advocacy, commitment and action to protect children. In addition, the approach puts the obligation on society rather than a single sector to ensure the health of children. 2,3. Perhaps within the context of accelerating child survival to achieve the MDGs, a child s rights should be emphasised more than a child s needs. II. Under Five Mortality in Ghana After decades of steady decline in under-five mortality rates, the latest of a series of four Demographic and Health Surveys conducted in Ghana (GDHS of 1988, 1993, 1998 and 2003) indicate a worsening in the nation s infant and under-five mortality. There are variations by urbanrural residence, region, wealth quintiles and educational status of mothers. Even though under-five mortality appears to have stagnated in the wealthiest quintile and improved in the poorest quintile there exists significant inequality between the poor and the rich, also being significantly higher in the Northern and Upper West regions and varies between rural and urban areas. GDHS (2003) reports infant (birth to 11 months) mortality, child (1 to 4 years) mortality and under five (birth to 4 years) mortality as 64, 50 and 115 deaths per 1,000 live births respectively. Neonatal (first month of life) and post neonatal (1 to 11 months) are 43 and 21 per 1,000 live births respectively (Table 1). Table 1: Age Specific Mortality Rates Age-specific Mortality Per 1000 live births Infant (birth to 11 months) 64 Neonatal (first month of life) 43 Post-neonatal(1 to 11 months) 21 Child (1 to 4years) 50 Under 5(birth to 4 years) 115 Source: GDHS 2003 The data indicate that, one in nine children die before their fifth birthday. Neonatal deaths constitute approximately two-thirds of infant deaths, while infant mortality also constitutes about two-thirds of under-five mortality. While mortality between 1-11 months and 1-4 years old have reduced, neonatal mortality has stagnated and indeed constitutes about a third of all under-five mortality. 2

3 There is a clear indication that the greatest progress in trends was the fall between and 1989 to 1993 periods for children one to four years of age. There was also a smaller and statistically insignificant decrease in post neonatal mortality (1 to 11 months). However neonatal mortality has increased persistently since the five year period preceding 1988, increasing from 30 to 39 per thousand live births in 2003 for the period (Figure 1). Fig. 1: Trends in Ghana s Childhood Mortality Rates for the five year periods preceding the DHS: CMR (12 59 months), Post -NMR (1 11 months) and NMR (< 1 month) Source: 1988, 1993, 1998 and 2003 DHS CMR Post NMR NMR NMR (2003 GDHS) Over the last two decades, under-five mortality in Ghana has fallen by 28 percent. The above statistics suggest that the decline in mortality between 12 and 59 months of age accounted for 72 percent of this achievement whereas a drop in mortality between 1 and 11 months contributed 26 percent to the decline. Neonatal mortality does not appear to have changed significantly throughout this period. There is the need for in-depth analysis on factors contributing to high neonatal mortality so as to review programme effort to address this situation. There is also the likelihood that neonatal mortality may have been underestimated. It is difficult to identify a single factor that significantly contributed to the steady decline in U5MR after independence to 1978 when the EPI programme was started. More probably it is due to a combination of factors including the eradication of smallpox, the sustained reduction in poverty, increased provision of potable water, promotion of oral rehydration therapy, and improvement in medical care. An analysis of the age-specific rates indicated that the 72 percent drop in child mortality contributed to the 43/1000 live birth decline in under-five mortality. The rapid reduction in mortality between 1984 and 1989 is closely associated with increased immunization coverage, especially against measles. The proportion of fully immunized children increased from 1 percent in 1978 to 55 percent in 1985 when the EPI programme covered the entire country. Conversely, the annual measles cases declined steadily from about 120,000 when EPI was introduced in 1978 to 40,000 in 1989, saving an estimated 1200 lives annually. 3

4 The stagnation in under-five mortality is not peculiar to Ghana and has been seen in many sub- Saharan and South Eastern Asia countries. This stagnation is not likely to be due to HIV/AIDS. Fortunately, most countries of West and Central Africa are not confronted with a high prevalence of HIV. Ghana is one of seven such countries in sub-saharan Africa with a median HIV prevalence of 3.2 percent. 4 Most countries with a high prevalence in HIV/AIDS have experienced stagnation or reversal of gains made. Moreover, some countries have also experienced economic stagnation. Causes of Under-five Mortality Analysis of the causes of under-five mortality indicates that the main factors are: early neonatal conditions (27%), malaria (25%), pneumonia (20%), diarrhoea (17%) with HIV and measles contribution 8 and 3% respectively. Overall,, over half (53%) of under-five deaths are related to malnutrition 5 (Fig. 2). GDHS data also show stagnation in the prevalence of stunting (30%), which is consistently worse in the rural areas and occurs in spite of evidence that the prevalence of exclusive breastfeeding has risen considerably, from 2% of 4 to 5 month old children in 1993 to 39% of such children in The median duration of exclusive breastfeeding is two months. The policy recommends exclusive breastfeeding for six months and the addition of complementary foods with breastfeeding for up to two years. Fig. 2: Causes of under - five mortality in Ghana (contribution of associated malnutrition is shown by the shaded ellipse) Source: Lancet Child Survival Series with adjustments for Ghana 3% 8% 27% Early neonatal 25% 53% 17% Diarrhoea Pneumonia Malaria Measles AIDS Malnutrition 20% Globally, causes of neonatal mortality are known to include prematurity (28%), pneumonia/sepsis (26%), asphyxia (23%), congenital disorders (8%), Tetanus (7%), diarrhea (3%) and other causes (7%). Recent data from the Komfo Anokye Teaching Hospital indicate that the causes of neonatal mortality comprise asphyxia (36%), prematurity (29%), sepsis (9%), Congenital causes (7%), birth injury (3%) and 16% for other causes 6 (Fig. 3). Fig. 3:Major reported causes of Neonatal Deaths at KATH Aug Jul 2005 Birth Inj related 3% Sepsis 9% Cong Abn 7% Others 16% Prematurity 28% 37% 4 Asphyxia

5 Ghana Demographic and Health Survey (GDHS) data also show that throughout the last two decades children born after birth intervals of less than 24 months have significantly higher underfive mortality than those born after longer birth intervals. Children born after birth intervals of 4 years or longer have the lowest under-five mortality but there is once again a suggestion that the under-five mortality among this group has stagnated since the early 1990s. The percentage of women delivering after birth intervals of less than 24 months has itself hit a plateau after years of steady decline (Fig 4). Benefits of birth spacing to mothers and their infants and children are well known. For mothers, these include a lower risk of maternal death, puerperal endometritis, premature rupture of membranes, anaemia and third trimester bleeding, while for the infant or child, there are lowered risks of death at all ages child, infant, neonatal and foetal deaths, preterm and low birth weight babies and stunting and underweight. 7,8 These have clear implications for neonatal, child and maternal health and particularly birth spacing through family planning. Fig. 4: Trends in the under-five mortality rate during the ten year period preceding the DHS, by birth interval Source: 1988, 1993, 1998 and 2003 GDHS <2 years 2-3 years 4+ years Programmes directed at under-fives Programmes for Under- Fives Child Welfare Services include: promotion of exclusive breastfeeding for the first six months and weaning diets, immunization, vitamin A supplementation, growth monitoring and nutrition rehabilitation and curative care for minor ailments and injuries. The integrated management of childhood illnesses (IMCI) is a broad strategy to reduce under-five mortality and morbidity, promote growth and development, focusing on the five causes which contribute to 70 percentof under five deaths: malaria, pneumonia, measles, diarrhoea and malnutrition. The three components of IMCI are: Improvements in the case management skills of first level health staff; improvements in the health system required for effective management of childhood illnesses; and improvements in family and community practices. These also include the safe motherhood programme which covers care during pregnancy, delivery and in the post natal period as well as family planning and infant 5

6 care (including breast feeding), sets the stage for optimal pregnancy outcome and is critical for good neonatal health. III. The School Health Programme The school health programme targets children between ages 5 and 15 years in schools. School health service is defined as effective and efficient provision of health service to pupils/students through schools to prevent, reduce, treat and monitor their health problems/conditions as well as promote health and well being. It also provides an opportunity to give messages about health and disease prevention to children that can be spread to their families and communities in which they live. The vision and mission of the School Health Programme are as follows: Vision A Healthy School Population, Well Informed and Equipped With Life Skills Needed To Adopt and Maintain Healthy Behaviour, Supported By a Responsive Health System. Mission Statement To Provide Accessible Comprehensive Health Services Within The School And Through Referral To The External Health System. These Services Will Integrate Preventive, Promotive, Curative And Rehabilitative Activities Including Specific Interventions That Are Best Carried Out Through The School. School health is an integral part of the child health programme and a priority area of the health sector in general. Poor health in school children, e.g. poor nutrition, worm infestation, accidents, injuries, poor vision, hearing problems, non-use of iodated salt, etc has been recognized to be important not only for physical development, but also for educational achievement since it leads to absenteeism and a reduction in active learning capacity. School health services can help to treat, prevent, reduce and monitor these health problems. School health services include: screening and examination of school children and food vendors, immunization, health education on current public health issues, management of minor ailments and injuries and maintenance of a hygienic school environment. Thus effective school health programmes are viable means to simultaneously address the inseparable goals of Health for All and Education for All. Substantial evidence indicates that health influences learning and education influences health. Increasing evidence also shows that school health programmes offer high cost-benefit ratios. 9 6

7 Adolescent Health and Development Adolescence is the transitional period between childhood and adulthood. Adolescents (10 to 19 years) and youth (15-24 years) constitute young people (10 to 24 years). In addition pre-adolescents (ages 5 to 9 years) are targets for comprehensive adolescent health and development (ADHD) programming. Health Profile of Adolescents Most adolescents are said to be healthy because they show low levels of illnesses and deaths as compared to younger children and adults. To the contrary, the GDHS and other studies reveal the magnitude of sexual and reproductive health problems of young people. These problems range from inadequate knowledge to sexual and reproductive health problems to their negative effects on the development of young people, families and society as a whole. These problems result from the responses to the developmental changes taking place with the youth and society. The GDHS 2003 reports the median age for menarche at 13.8 years, age at first sex is 18.3 years with a minimum at 10 to 12 years, girls appear to initiate sex earlier than boys but at age 20 years 80% of both sexes have had sex. Age at first marriage indicates an increasing trend - from 18.3 years in 1993 to 19.6 years in Births to teenage mothers constituted 20.3% of the age cohort. Contraceptive use among adolescents is low (less than 10%) with a high unmet need of 57%. There is a high knowledge of HIV/AIDS (97%) with lower figures for other specific sexually transmitted infections (STIs). The female to male ratio of HIV is 4:1 compared to the ratio of the general population of 2:1, this implies that female adolescents are disproportionately vulnerable to HIV/AIDS and other STIs (Table 2). Table 2: Some Characteristics of Adolescents in Ghana Median age at menarche 13.8 years Age at first marriage 19.6 (2003) 19.3 (1998) 18.3 (1993) Age at first sex Minimum Boys (15-19 years)/by Age 18 years Girls (15-19 years)/by Age 18 years By Age 20 years (both Sexes) Age at First Birth 18.3 years yrs 19.3%/25% 38%/48% 80% 20.5 years Early Births (to mothers below 20 years) 23.0% 7

8 Contraception (15-19 years) Contraceptive Use Unmet need Spacing Limiting STI Knowledge Gonorrhoea: Boys/Girls Syphillis : Boys/Girls Herpes Hepatitis Other : Boys/Girls 6.9% 57.0% 53% 4% Awareness of HIV/AIDS (Young People) 97% HIV Infection Female:Male Ratio (General Population) Adolescents Contraception (15-19 years) Contraceptive Use Unmet need Spacing Limiting STI Knowledge Gonorrhoea: Boys/Girls Syphillis : Boys/Girls Herpes Hepatitis Other : Boys/Girls 45.7%/40.7% 12.4%/10.6% 1% 0.2% 1.7%/1.3% 2:1 4:1 6.9% 57.0% 53% 4% Awareness of HIV/AIDS (Young People) 97% HIV Infection Female:Male Ratio (General Population) 2:1 Adolescents 4:1 Source: GDHS %/40.7% 12.4%/10.6% 1% 0.2% 1.7%/1.3% 8

9 Fig. 5: Age of Adolecent Pregnancy, % Coverage Year Source: Based on national data of teenage registrants at antenatal clinics The Adolescent Health & Development Programme The adolescent health and development programme aims at promoting the health of young people, preventing and responding to health problems from early, unprotected, unwanted sex, use and misuse of drugs including cigarettes and alcohol, poor nutrition, endemic diseases, violence and injuries. The vision, mission and goal of the Adolescent Health and Development Programme are: Vision To have a well-informed adolescent adopting healthy lifestyle physically and psychologically and supported by a responsive health system. Mission To make available appropriate information on young people s health and provide comprehensive adolescent health services including reproductive health. These services will be delivered in a humane, efficient and effective manner by trained, friendly, highly motivated and client oriented personnel. Goal To contribute to improved adolescent health through the provision of adequate health information and knowledge which will ensure behavioural change and increased utilization 9

10 of health services including reproductive health in both public and private health delivery systems in Ghana. Key Elements of the Adolescent Health and Development Programme include: adolescent rights and responsibilities; pre-adolescent and adolescent development, health promotion for adolescents including life skills education, healthy lifestyle, adolescent nutrition, counselling towards behaviour change, parenting adolescents, adolescents and family planning, adolescent pregnancy, childbearing and parenting, Sexually Transmitted Infections; HIV/AIDS; reproductive health problems affecting adolescent boys and girls, mental health and substance abuse, discouragement of harmful practices that affect adolescent development; social mobilization for adolescent reproductive health and appropriate teaching methodologies in ADHD programming. The major interventions include creating safe and supportive environment, providing accurate information, building life and livelihood skills, providing counselling services and improved health services. The main areas of ADHD programme implementation are: identification and management of common health problems affecting pre-adolescents and young people, provision of adolescent focused services including counselling, information, education and communication (IE&C) and reproductive health issues in general and referrals. Priority strategies include advocacy and awareness, enhanced opportunities to grow and develop, youth and community involvement, capacity-building, of stakeholders and institutions, youth friendly service delivery, protection from harmful practices, resource mobilization, monitoring and evaluation III. Challenges and Gaps in Child Health Programmes Health problems and needs for the various groupings of children and youth are diverse and have led to different programme components usually with varied and different sources of external funding. Consequently, there are different coordinating mechanisms, collaborators and partnerships at various levels of the health care system. There is low coverage of evidence-based, of effective interventions fraught with problems with data management and quality. These have also contributed to weakened linkages between child health and reproductive health and a worsening of neonatal health indices. For example, in recent years, little or no reference or funding commitments are made to benefits of child spacing and family planning in child health programming. There is a need for strengthened collaboration (including resource mobilization), through effective integration of services within the health sector and with other sectors such as the Ministry of Women and Children s Affairs, Education, Agriculture, Local Government among others as well as private sector including NGOs and Civil Society groups. Community ownership and partnership in matters relating to health is also crucial. In general coverage of health interventions is lowest among poor populations, raising questions about whether the poor should be specifically targeted 10. Achieving rapid reductions in mortality requires universal coverage (99 percent), but poor people are particularly difficult to reach because of geographical, economic or socio-cultural barriers to care. This calls for a twin-track approach where 10

11 universal coverage is aimed at, but additional investments are made to reach the poor. However, the selection of the targeting strategy should be done carefully to reduce administrative cost and stigmatization. The Under-Fives Programme: Proven cost-effective interventions are implemented under various programmes in Ghana. These have to be well targeted to increase coverage. For children under five years, these include use of insecticide treated bed nets by pregnant mothers and young children to improve neonatal outcome, breast feeding, immunization to prevent child mortality, clean delivery etc (Table 3). Table 3: Proven Cost Effective Interventions for Under-Fives Programmes Major causes of U5MR Malaria Proven cost effective interventions* Anti-malaria drugs ITN Implemented in Ghana, but coverage is low Diarrhoea Acute respiratory infection Measles Malnutrition ORS Breast feeding Complementary feeding Water, sanitation, and hygiene Hib vaccine Antibiotic Complementary feeding Vaccination Vitamin A supplementation Breast feeding Complementary feeding, but median duration of exclusive breast feeding is 2months, sanitation is a growing problem, but dispensing not permitted at community level, but frequency and quality of foods should be improved Managing the neonate 1. Preterm delivery ITN IPT 2. Tetanus Vaccine Clean delivery, but proportion of professional skilled attendance low 3. Sepsis Breastfeeding Source: Bainson K. A., Kwashie S.T., Appah B., Pond B. (2005). Individual targeting through some means testing involves a large administrative cost and tends to stigmatize the poor. Categorical targeting i.e. targeting a population group is feasible, because it is associated with lower administrative cost and low stigmatization. Ghana has adopted this twintrack approach: EPI has been scaled up nationally but UNICEF and USAID have targeted support to the Upper East region and twenty eight deprived districts respectively. Out of 138 districts the 11

12 coverage is not very great and districts and regions which were previously doing well lack resources and could show a worsening of indicators and gains made. The School Health Programme The major gap in the school health programme is that it does not reach the school age child who is not in school. Children in this group are very vulnerable and have to be reached. The success of the school health programme depends on the joint commitment and partnership of the health and education sectors. The ADHD Programme This is a fairly new area and needs support and commitment of all including parents, community, health workers and the adolescents themselves. Until recently, health service statistics were not disaggregated by age and sex specifically for this age group, therefore there is very little systematic data collected for adolescent health programming. The target group of the ADHS programme is not homogenous. Within the adolescent health and development programme there needs to be targeting of specific subgroups such as married adolescents, in school, out of school, urban, rural etc. A holistic programme requires partnership with other sectors. For example while the health sector focuses on youth friendly service delivery, the need for education and livelihood skills and economic empowerment has to be available from the relevant sectors. IV. Prospects and Way Forward: Commitment to the health and welfare of children has been demonstrated by all governments and has always been a priority area of the health sector programme. The vulnerability of mothers and young children has led to resource mobilization for maternal and child health services by the health sector. While much progress has been made in the area of child health including school health and, in recent years, adolescent health and development, there are many challenges to be overcome. It is clear that to reduce under-five mortality, future investments should be directed mainly at reducing neonatal mortality and mortalities due to malnutrition, malaria and pneumonia including scaling up of IMCI. A review the Child Health Policy (for under-fives) is currently ongoing. This will include new and emerging issues such as the pentavalent vaccine which is already in use with newer ones expected to be introduced by 2011, strengthen community systems and programs to address the high neonatal death rates. The Adolescent Health and Development and the School Health programme documents need to be implemented nationwide. The contribution of other sector policies such as free compulsory basic education (FCUBE), the feeding programme, the early Childhood and Development Policy etc. are all positive moves to improve child health especially through inter-sectoral collaboration. The analysis of under fives programmes in Ghana also indicate that future investments should mainly be directed at reducing neonatal mortality and mortalities due to malnutrition, malaria and pneumonia. Even though the contribution of HIV/AIDS is minimal, the disease should be closely monitored because of its potential to worsen. Crucial linkages between reproductive and child 12

13 health programmes need to be strengthened to improve neonatal, under-five, and adolescent health in particular. Lessons learnt from the child survival components of GOBI-FFF (growth monitoring, oral rehydration, breast feeding, immunization, complementary feeding, family planning and female education) should integrated in the programming. Unfortunately, it appears that in the case of family planning, the benefits of birth spacing, is receiving less attention in programming for child health.. Using the rights based approach, advocacy should be promoted to foster effective inter-sectoral collaboration, resource mobilization, integration of health programmes with community based services such as the Community-based Health Planning and Services (CHPS) programme and national development agendas such as the Ghana Poverty Reduction Strategy. These translated into greater political commitment will foster ownership of programmes and strategies at all levels and improve resource mobilization and utilization towards the achievement of national l health goals for the children and youth in Ghana. 1 Ministry of Health, Ghana Health Service, UNFPA (2005): National Adolescent Health & Development Programme: Training Manual for Health Care Providers in Ghana 2 Culyer, A.J. and A. Wagstaff.(1993). Equity and Equality in Health and Health Care. J.Health Econ.12: Bainson K. A., Kwashie S.T., Appah B., Pond B. (2005). An Analytic Review of IMCI in the Context of Child Health in Ghana: A Key Area Review Report for the Annual Health Sector Review Ghana Health Service National HIV/AIDS Control Programme, Sentinel Site Report 5 Neonatal Survival Series 1. vol. 365 March,2005 (accessed 10 March, 2005) 6 Addo-Yobo E.O.D., MD FGCP MWACP MSC DTCH, Specialist Paediatrician/Senior Lecturer Department of Child, SMS-KNUST/KATH, KUMASI, Presentation- Reducing Birth Asphyxia Through Skilled Attendance At Birth A Vital Key To Reducing Infant Mortality: Presented at the Reproductive and Child Health Biannual Review Meeting, Busua Beach Resort, Western Region Ghana, September 26 th Conde-Agudelo A., Effect of Birth Spacing on Maternal and Perinatal Health: A Systematic Review and Meta- Analysis. Rutstein, S. Johnson & Conde-Agudelo A. Systematic Literature Review and Meta-Analysis of the Relationship between Inter pregnancy or Inter birth Intervals and Infant and Child Mortality. Reports submitted to CATALYST Consortium, October Conde-Agudelo, A. and Belizan, J.M. Maternal morbidity and mortality associated with interval: Cross sectional study. British Journal (Clinical Research Ed.) 321 (7271): Nov. 18, Ghana Health Service (2005): Guidelines for Provision of School Health Service in Ghana 10 Gwatkin, D. (2001). The Need for Equity-oriented Health Sector Reforms. Int J. Epid, 30:

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