The fertility impact of achieving universal health coverage in an impoverished rural region of Northern Ghana

Abstract

Background:  When a successful Navrongo Health Research Centre service experiment demonstrated means for reducing high fertility and childhood mortality in a traditional societal setting of northern Ghana, the Ministry of Health launched a program of national scaling up known as the Community-based Health Planning and Services (CHPS) initiative. For two decades, CHPS has been Ghana’s flagship program for achieving universal health coverage (UHC). When monitoring during its first decade determined that the pace of CHPS scale-up was unacceptably slow, the Ghana Health Service launched the Ghana Essential Health Interventions Program (GEHIP) in four Upper East Region districts to test means of accelerating to CHPS implementation and improving its quality of care.   Methods:  To evaluate GEHIP, a two-round randomized sample survey was fielded with clusters sampled at baseline that were reused in the endline to facilitate difference-in-difference estimation of changes in fertility associated with GEHIP exposure.  Monitoring operations assessed the location, timing, and content of CHPS primary health care. Discrete time hazard regression analysis on merged baseline and endline birth history data permit estimation of GEHIP fertility and CHPS access effects, adjusting for hospital and clinical service access and household social and economic confounders.  Results: GEHIP exposure was associated with an immediate acceleration of CHPS implementation and coverage. Women residing in households with CHPS services had only slightly lower fertility than women who lacked convenient access to CHPS. GEHIP impact on contraceptive use was statistically significant but marginal; GEHIP exposure was associated with increasing unmet need.  Conclusion: Results challenge the assumption that achieving UHC will reduce excess fertility.  Social mobilization, community-outreach, connection of family planning discussions with male social networks are elements of the Navrongo success story that have atrophied with CHPS scale-up.  Achieving UHC does not address the need for renewed attention to these family planning focused strategies.