Akalpa J Akaligaung

A growing body of research in West Africa and globally shows that cash transfers can decrease intimate partner violence (IPV). The purpose of this study was to explore how the government of Ghana's Livelihood Empowerment Against Poverty (LEAP) 1000 program, an unconditional cash transfer plus health insurance premium waiver targeted at pregnant women and women with young children, influenced IPV experiences. Existing program theory hypothesizes three pathways through which cash transfers influence IPV, including: 1) increased economic security and emotional wellbeing; 2) reduced intra-household conflict; and 3) increased women's empowerment. Informed by this theory, we conducted qualitative in-depth interviews with women in northern Ghana (n = 30) who were or had been beneficiaries of LEAP 1000 and had reported declines in IPV in an earlier impact evaluation. We used narrative and thematic analytic techniques to examine these pathways in the context of gender norms and household dynamics, as well as a fourth potential pathway focused on interactions with healthcare providers. Overall, the most prominent narrative was that poverty is the main determinant of physical IPV and that by reducing poverty, LEAP 1000 reduced conflict and violence in households and communities and improved emotional wellbeing. Participant narratives also supported pathways of reduced intra-household conflict and increased empowerment, as well as interplay between these three pathways. However, participants also reflected that cash transfers did not fundamentally change gender norms or reduce gender-role strain in a context of ongoing economic insecurity, which could limit the gender transformative potential and sustainability of IPV reductions. Finally, while health insurance increased access to healthcare, local norms, shame, fear, and minimal provider screening deterred IPV disclosure to healthcare providers. Additional research is needed to explore interplay between pathways of impact across programs with different design features and implementation contexts to continue informing effective programming to maximize impact.

Background Expanding health insurance coverage is a priority under Sustainable Development Goal 3. To address the intersection between poverty and health and remove cost barriers, the government of Ghana established the National Health Insurance Scheme (NHIS). Government further linked NHIS with the Livelihood Empowerment Against Poverty (LEAP) 1000 cash transfer program by waiving premium fees for LEAP 1000 households. This linkage led to increased NHIS enrolment, however, large enrolment gaps remained. One potential reason for failure to enroll may relate to the poor quality of health services. Methods We examine whether LEAP 1000 impacts on NHIS enrolment were moderated by health facilities’ service availability and readiness. Results We find that adults in areas with the highest service availability and readiness are 18 percentage points more likely to enroll in NHIS because of LEAP 1000, compared to program effects of only 9 percentage points in low service availability and rea...

Quality improvement (QI) is used to promote and strengthen maternal and child health services in middle- and low-income countries. Very little research has examined community-level factors beyond the confines of health facilities that create demand for health services and influence health outcomes. We examined the role of community outreach in the context of Project Fives Alive!, a QI project aimed at improving maternal and under-5 outcomes in Ghana. Qualitative case studies of QI teams across six regions of Ghana were conducted. We analysed the data using narrative and thematic techniques. QI team members used two distinct outreach approaches: community-level outreach, including health promotion and education efforts through group activities and mass media communication; and direct outreach, including oneon- one interpersonal activities between health workers, pregnant women and mothers of children under-5. Specific barriers to community outreach included structural, cultural, and ...

ABSTRACT Background: Project Fives Alive! (PFA) utilizes quality improvement (QI) methods to assist Ghana's faith-based and public health services to achieve Millennium Development Goal 4, a 66% reduction in under-5 mortality, by improving the continuum of care from pregnancy through age five. The purpose of this study is to understand factors associated with QI team effectiveness and the role of community relationships in QI team performance. Methods: A qualitative case-study approach (n=12 cases) was taken across 6 regions of Ghana including in-depth interviews with health staff (n=66) and field observations. Analysis entailed developing narrative summaries for each case and systematic topical coding around emergent themes. Results: The achievement of program targets of increased maternal and child health (MCH) service coverage is affected by how QI teams engage with their communities. High achieving QI teams engage communities in relationship building and adapt their work to sociocultural beliefs. Low achieving teams often attribute low achievement to sociocultural norms. The way in which QI teams orient themselves positively or negatively toward community beliefs and how they engage communities in health education, outreach, and promotion of facility health services affects achievement of program goals. Conclusions: Findings indicate that capacity-building of healthcare staff through QI initiatives should include strengthening community engagement skills and address the perceived barrier of sociocultural norms. Working with communities to promote the use of existing MCH services and to address resource constraints contribute to the success of the QI team approach.