The maternal mortality rate in Ghana is “unac-

ceptably high” at 540 deaths per 100,000 births

in 2000. From 1993 to 2003, life expectancy at

birth was only 56 years for males and 57 years for

females. Estimates of the under-five mortality rate

(ages 0 to 5 years) ranged from 102 to 110 deaths per

1,000 live births.

The health of mothers and children remains more

precarious in rural areas of Ghana than in cities and

towns. Infant mortality was 70 deaths per 1,000 live births

in rural areas compared to 55 deaths per 1,000 in Ghana

overall. Pregnant women and young children in rural

areas are especially vulnerable to acute respiratory infec-

tions, diarrhea, malaria, and other preventable and treat-

able diseases. Malaria is responsible for 40 percent of

outpatient visits in Ghana, is the country’s leading cause

of death, and accounts for 25 percent of child mortality.

BackgroundImprovements in maternal and child survival are two of

the United Nations Millennium Development Goals that

are achievable with programs such as CHPS (the

Community-based Health Planning and Services proj-

ect). CHPS is a national program in Ghana that assigns

trained nurses to live in rural villages and become mem-

bers of these communities. CHPS nurses provide basic

curative and preventive health services, including free

door-to-door maternal and child health visits. A neglect-

ed Millennium Development Goal that will also con-

tribute to improvements in maternal and child health

care is the equitable distribution of essential medicines,

particularly in impoverished rural communities such as

those in which CHPS operates. The Population Council

believes that the equitable distribution of essential medi-

cines that prevent and treat the most common diseases

will play an increasing role in achieving all of these inter-

nationally established goals.

Assessing the equitable distribution of essential medicines for rural maternal and child health care: Baseline report, Nkwanta District, Ghana

P R O G R E S S R E P O R T

J U N E 2 0 0 7

Scenes of Nkwanta district: (top) Adolescentmother and child receiving health care services at KecheibiCHPS compound; (left) two young boys inSibi Central CHPS zone.

www.popcouncil.org/projects/SS_GhanaGEMI.html

Nevertheless, current standards and protocols for

life-saving drugs established by both the World Health

Organization and the United Nations have been inade-

quate in ensuring availability and access. Remote rural

communities, such as those served by CHPS in

Nkwanta district, have access to only a small fraction of

the 350 drugs on WHO’s Essential Medicines List and

have fewer medications than are available in subdistrict

health centers located in larger towns. (Figure 1 indi-

cates the percentage of 70 essential medicines that are

usually in stock at rural health facilities.)

Ghana’s Ministry of Health has established a

national “cost-exemption” policy, under which the impov-

erished, children under age five, pregnant women, and

the elderly are entitled to free access to essential drugs.

However, because CHPS has increased both access to

and demand for medical care, the cost-exempt essential

medicines programs in rural districts face the threat of

bankruptcy.

Launching GEMIGEMI is a private–public partnership between Nkwanta

district in rural Ghana, a consortium of US-based pharma-

ceutical companies, Oak Foundation, and the Population

Council, a nonprofit research organization with headquar-

ters in New York and a regional office in Accra.

On 27 April 2007, Dr. Elias Sory, Director General

of the Ghana Health Service, launched the GEMI project

at a traditional community gathering and celebration

known as a durbar. GEMI’s goal is to improve the equi-

table distribution of essential medicines in rural areas

such as Nkwanta.

Dr. Sory described the nature of drug availability in

rural Ghana as follows: “CHPS has made it possible for

Community Health Officers to move from house to house,

thus enabling them to reach more ‘exemption cases’ than

there are free drugs to offer.” To address the problem of

drug shortages, GEMI will test ways of ensuring that all

eligible households have access to basic drugs.

GEMI has provided over US$600,000 to

increase the supply and quality of drugs available in

impoverished rural areas. Essential medicines are pur-

chased locally in Ghana, and GEMI has developed a

quarterly monitoring system that tracks and reports on

drug availability and affordability for 70 essential drugs

in the district. The project supports the efforts of

CHPS nurses, who provide much-needed health care

to rural women of reproductive age and to children

under the age of five.

Preliminary findingsBetween January and March 2007, the Nkwanta Health

Development Centre (NHDC) designed and tested the

quarterly monitoring system, tracking drug inventories at

each district facility. In March, the NHDC research team

completed training in the use of hand-held devices that

permit the accurate collection and recording of data in a

timely fashion.

Figure 1: Percent of essential drugs (n=70) usually in stock inrural facilities by disease and facility type

Figure 2: Drug availability at rural CHPS facilities by disease

Figure 3: Average length of stockouts for essential drugs usually in stock, at CHPS and other facilities

Malaria

Diarrhea

ARI

Other

74%78%

80%90%

75%88%

57%71%

0% 20% 40% 60% 80% 100%

100%

80%

60%

40%

20%

0%Malaria Diarrhea ARI Other

Usually in stockCurrently in stockUnexpired currently in stock

Stockout(3 months)

Stockout(2 months)

Stockout(1 month)

In stock(3 months)

0% 10% 20% 30% 40% 50%

14%22%

16%18%

23%24%

46%

35%

CHPS Subdistrict health centres

CHPS Subdistrict health centres

Main reasons for drug stockouts in all

district facilities

• Provider didn't request/unaware (44%)

• Drug was out of stock at district (32%)

• Low demand/usage (17%)

• High demand/usage (7%)

Main reasons for expired drugs

• Drug was out of stock at district

• Provider not aware of expiration date

• Low demand/usage

Researchers routinely record the following:

• Average number of available drugs usually in

stock at hospitals and at subdistrict and CHPS

facilities

• Percentage of drugs currently in stock

• Percentage of drugs that are not expired

Among their findings:

• Although CHPS has better performance quality

than other facilities, the number of drugs available

is limited.

• CHPS nurses do not recover costs for door-to-door

services, which greatly reduces their revenue

potential to purchase more drugs.

(Left to right) Scene at CHPS durbar in Agou-Fie; Kecheibi Chief pouring ancestral libations; male dancers preparing for the durbar festivities.

RecommendationsOn the basis of these key findings, the GEMI research

team has recommended that the district implement the

following basic remedies:

• Design a local group insurance system for CHPS

zones to allow for greater recovery of costs and

purchase of additional medicines.

• Develop a GEMI in-service training curriculum for

the proper supply, handling, storage, and prescrip-

tion of essential medicines for CHPS nurses.

• Increase the diversity of family planning methods,

including emergency contraception.

• Include new mothers in community health talks to

teach them awareness of prevention, symptoms,

and appropriate services needed for common

childhood diseases.

What’s next for GEMI?While the first batch of GEMI drugs are being pur-

chased and supplied to the first two CHPS zones, the

research team is preparing for a district-wide household

survey. Based on international indicators, researchers

will collect data from reproductive-age women on avail-

ability and affordability of health care and on women’s

accurate health knowledge and health-seeking behav-

ior. The survey will be piloted in July and implemented in

Fall 2007.

Partners

Dr. Koku Awoonor-WilliamsDistrict Director of Health Services, Ghana Health Service

Stella AnkuCHPS Coordinator, Ghana Health Service

Nutifafa GloverHealth and Nutrition Officer, Ghana Health Service

George BimpehGEMI Director of Research, Ghana Health Service

Abigail HolmanConsultant

Maya Vaughan-SmithStaff Associate, Population Council

James PhillipsSenior Associate, Population Council

Santuah NiagiaCommunications Specialist, Population Council, Accra

Melissa MayPopulation Council, New York

Christina Tse Population Council, New York

GEMI Field Research and Logistics Team

Donors

Wyeth Pharmaceuticals

Anonymous Corporate Partners

The Mascotte Family Fund of the AspenCommunity Foundation

Oak Foundation

Photo credits: Abigail Holman, Melissa May, James F. Phillips, Maya Vaughan-Smith

N O T E S F R O M T H E F I E L D

Mercy Mensah (age 28) moved to Azua as a CHPS

nurse 10 months ago. Daily, she rides her motor-

bike to isolated villages to give community health talks

and make routine house calls.

Before starting her rounds, she discusses her

planned activities with the chief. A community health volun-

teer in the village acts as a town crier by beating the gong-

gong to announce the nurse's arrival, and community

members mobilize residents to meet in the village center.

The Nkwanta Health Development Centre has start-

ed a district-wide Health Ambassadors Program that

Mercy has successfully introduced in her village. She has

recruited rural youth from ages 10 to 19 to become

health volunteers and educators. The district provides

competitive scholarship opportunities for active members

to continue their education in a health-related field. The

Ambassadors meet weekly to discuss prevention of

malaria, HIV, cholera, and water-borne diseases and ill-

nesses. They have formed a drumming troupe that gives

entertaining health talks in villages.

When asked about the favorite part of her job,

Mercy confidently remarked that she can now inde-

pendently direct and manage her own facility, which

has given her an invaluable and unique experience in

the nursing profession.

CHPS nurse Mercy Mensah and commmunity health volunteers conducting a weekly child welfare clinic in Azua CHPS zone.

GEMI is a private–public partnership between

Nkwanta district in Ghana, a consortium of

US-based pharmaceutical companies,

Oak Foundation, and the Population Council, a

nonprofit research organization with headquar-

ters in New York and a regional office in Accra.

Maya Vaughan-SmithPoverty, Gender, and Youth ProgramPopulation CouncilOne Dag Hammarskjold PlazaNew York, NY 10017mvaughan@popcouncil.org Tel: +1 212 339 0500

Dr. Koku Awoonor-WilliamsExecutive Director, Nkwanta Health Development Centre,

Nkwanta Medical VillageP.O. Box 54, Nkwanta V/RGhanakawoonor@gmail.com

© 2007 The Population Council, Inc. www.popcouncil.org

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