PLOS ONE
RESEARCH ARTICLE
Contribution of child health interventions to
under-five mortality decline in Ghana:
A modeling study using lives saved and
missed opportunity tools
Augusta Kolekang 1ID *, Bismark Sarfo2, Anthony Danso-Appiah2, Duah Dwomoh2,
Patricia Akweongo2
1 School of Public Health, University for Development Studies, Tamale, Ghana, 2 School of Public Health,
University of Ghana, Legon, Accra, Ghana
a1111111111 * augustakolekang@yahoo.com
a1111111111
a1111111111
a1111111111 Abstract
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Background
Increased coverage of interventions have been advocated to reduce under-five mortality.
OPEN ACCESS However, Ghana failed to achieve the Millennium Development Goal on child survival in
Citation: Kolekang A, Sarfo B, Danso-Appiah A, 2015 despite improved coverage levels of some child health interventions. Therefore, there
Dwomoh D, Akweongo P (2022) Contribution of is the need to determine which interventions contributed the most to mortality reduction and
child health interventions to under-five mortality
those that can further rapidly reduce mortality to inform the prioritization of the scale-up of
decline in Ghana: A modeling study using lives
saved and missed opportunity tools. PLoS ONE interventions.
17(8): e0267776. https://doi.org/10.1371/journal.
pone.0267776 Materials and methods
Editor: Mary Hamer Hodges, Njala University, Deterministic mathematical modeling was done using Lives Saved and Missed Opportunity
SIERRA LEONE
Tools. Secondary data was used, and the period of the evaluation was between 2008 and
Received: September 14, 2021 2014. Some of the interventions assessed were complementary feeding, skilled delivery,
Accepted: April 15, 2022 and rotavirus vaccine.
Published: August 1, 2022
Results
Copyright: © 2022 Kolekang et al. This is an open
access article distributed under the terms of the A total of 48,084 lives were saved from changes in coverage of interventions and a reduction
Creative Commons Attribution License, which in the prevalence of stunting and wasting. Reduction in wasting prevalence saved 10,372
permits unrestricted use, distribution, and
(21.6%) lives, insecticide-treated net/indoor residual spraying 6,437(13.4%) lives saved,
reproduction in any medium, provided the original
author and source are credited. reduction in stunting 4,315(9%) lives saved and artemisinin-based combination therapy
(ACTs) 4,325(9.0%) lives saved. If coverage levels of interventions in 2014 were scaled up
Data Availability Statement: The data used are
available in the Lives Saved Tool available at www. to 90% in 2015, among neonates, full supportive care for prematurity (5,435 lives saved),
avenirhealth.org. full supportive care for neonatal sepsis/pneumonia (3,002 lives saved), and assisted vaginal
Funding: The author(s) received no specific delivery (2,163 lives saved), would have saved the most lives among neonates, while ACTs
funding for this work. (4,925 lives saved), oral rehydration salts (ORS) (2,056 lives saved), and antibiotics for the
Competing interests: The authors have declared treatment of pneumonia (1,805 lives saved) would have made the most impact on lives
that no competing interest exist. saved among children 1–59 months. Lastly, if all the interventions were at 100% coverage in
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PLOS ONE Contribution of child health interventions to under-five mortality decline in Ghana
2014, the under-five mortality rate would have been 40.1 deaths per 1,000 live births in
2014.
Discussion
The state of the package of interventions will likely not lead to rapid mortality reduction. Cov-
erage and quality of childbirth-related interventions should be increased. Additionally, ave-
nues to further reduce stunting and wasting, including increased breastfeeding and
complementary feeding, will be beneficial.
Introduction
Increased coverage of Maternal, Neonatal, Child Health, and Nutrition (MNCHN) interven-
tions have been advocated during the period of the Millennium Development Goals (MDGs)
and beyond that aimed to reduce under-five mortality (U5M) [1,2]. However, although Ghana
achieved some increase in coverage of interventions during the period, it failed to achieve the
MDGs target of a 75% decline in U5M between 1990 and 2015 [3] and is not on track to
achieving the Sustainable Development Goal (SDG) 3.2 [4]. Ghana needed to achieve a U5M
rate of about 40 deaths per 1,000 live births in 2015 to achieve the target, but U5M in 2014 was
about 60 deaths per 1,000 live births [3]. Also, the Greater Accra and Ashanti Regions of
Ghana, which had the lowest mortality rates historically, had the slowest U5M rate decline of
62 to 47 deaths per 1,000 live births and 78.2 to 80 deaths per 1,000 live births, respectively,
compared to the national rate decline of 108 to 60 deaths per 1,000 live births between 1998
and 2014 [3,5]. These point to a possible stagnation and increase in mortality in the future.
Progress in reducing neonatal deaths also lags compared to deaths after the neonatal period,
with reports of an increasing proportion of neonatal deaths in some countries [6,7]. This calls
for the prioritization of interventions implemented to scale-up high-impact interventions for
maximum impact on U5M decline.
One of the earliest efforts at implementing interventions for the prevention of child mortal-
ity started in Ghana in 1978 with the introduction of the Expanded Programme on Immuniza-
tion (EPI) [8]. Since then, several interventions have been introduced, and strategies to
increase coverage of interventions implemented. The most recent addition to the pool of inter-
ventions was the malaria vaccine introduced in 2019 [9]. Vaccines had the highest coverage
levels among the interventions being implemented that can affect U5M in Ghana. In contrast,
water and sanitation interventions had the lowest coverage levels according to the 2014 Ghana
Demographic and Health Survey (GDHS).
The Community-based Health Planning Services (CHPS) and the National Health Insur-
ance Scheme (NHIS) are some strategies to increase access to healthcare services and, conse-
quently, the coverage levels of interventions in Ghana [10]. However, increased coverage of
interventions will not yield the needed mortality decline if implemented interventions are inef-
fective [11]. Differences in the impact of these interventions are expected with differences in
the prevalence of diseases, risk factors, and over time. With the slow pace of progress in child
survival in Ghana, there is the need to assess how these interventions impact child survival.
The objective of this study was to evaluate the contribution of the various child health inter-
ventions to mortality decline between 2008 and 2014 and those with the potential to further
contribute to mortality reduction if their coverage levels are increased.
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PLOS ONE Contribution of child health interventions to under-five mortality decline in Ghana
Materials and methods
Study design
Deterministic mathematical modeling was done using Lives Saved Tool (LiST) and Missed
Opportunity Tool (MOT) [12]. A demographic module (DemPro), family planning module
(FamPlan), and AIDS impact module (AIM) were used as part of the LiST analysis. These
tools are part of a suite of policy modeling tools in the spectrum software available at www.
avenirhealth.org. Version 6.08 was used.
The LiST is a multi-cause deterministic mathematical population-level modeling tool used
for evaluation and attribution. It can be used to evaluate the impact of multiple interventions
or programmes implemented simultaneously. There were over 70 interventions in LiST at the
global level as of 2011. The LiST has been validated and used in studies in several countries
including Ghana [13–19]. It was used to model the number of lives saved and percent mortal-
ity rate reduction based on changes in intervention coverage levels and the decrease in the
prevalence of stunting and wasting in this study [20–23].
In general, if coverage levels increase for the interventions, children who were previously
unprotected from death due to lack of use of these interventions become protected. Therefore,
additional lives are saved, or excess deaths are prevented due to the interventions relative to
the previous coverage levels. Conversely, if coverage levels are reduced, it results in excess
deaths, while no change in coverage results in zero lives saved. The interventions used in this
analysis were those with coverage level information in the LiST. For stunting and wasting, a
decrease in their prevalence reduces the risk of infections such as malaria, diarrhoea, and
pneumonia and, consequently, deaths from these conditions.
The MOT determines the interventions that will make the most impact if intervention cov-
erage levels were individually scaled up to 90%, one at a time, one year from the baseline year
[12]. It, therefore, estimates the future potential impact of interventions, and thus, those to
focus on to accelerate mortality decline. Although 90% is the default coverage level in the
missed opportunity tool, it is also the target coverage level of vaccines and other interventions
for the Ghana Health Service [24].
Sources of data
The lives saved tool contains default data of several countries from different sources, including
household surveys such as the Demographic and Health Surveys (DHS), Multiple Indicator
Cluster Survey (MICS), and Malaria Indicator Survey (MIS), the World Health Organization
(WHO), and the United Nations Children Emergency Fund (UNICEF). Coverage of maternal
and child health intervention data comes from surveys such as DHS, MICS, and MIS, apart
from vaccines from the WHO/UNICEF. Water and sanitation-related interventions come
from the WHO/UNICEF Joint Monitoring Program for water supply and sanitation (WHO/
UNICEF-JMP). Mortality rate data comes from the UN Inter-agency Group for Child Mortal-
ity Estimation (IGME). Coverage levels of some interventions for which data is not available
are modeled using other intervention coverage levels, or assumptions are made on their cover-
age levels. Appendix A contains interventions in LiST on which data is available in Ghana.
Lives saved tool modeling strategy
The lives saved tool makes a projection of the population under study using the DemPro
(demographic projection) and calculates births and deaths that should occur in that popula-
tion. The effect of family planning services on the number of births is applied using informa-
tion from the FamPlan module. At the same time, the effect of AIDS on mortality is also
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PLOS ONE Contribution of child health interventions to under-five mortality decline in Ghana
applied using information from the AIM (AIDS impact module). With the number of deaths
estimated, coverage of interventions to reduce mortality is applied to the population. Based on
the effectiveness of the intervention(s) delivered in that population, the projected deaths are
expected to change relative to the changes in coverage of the interventions since the interven-
tions are expected to reduce the number of deaths that should occur in the population.
The basic formula for calculating the impact is impact = change in intervention coverage X
effectiveness of intervention X affected fraction. Adjustments are made to this basic formula to
account for previous lives saved and the herd effect of vaccines and bed net. Details of the
modeling strategy are built in the LiST and published [25].
Intervention effectiveness is effectiveness established at the global or regional levels. It is in
the LiST, while the affected fraction is the fraction of cause-specific mortality amenable to the
particular intervention which is also in the tool [25].
The timeframe for the modeling was from the year 2008 to 2014. 2008 and 2014 were cho-
sen because they are closest to the end of the Millennium Development Goals (MDGs) and the
beginning of the Sustainable Development Goals (SDGs). Therefore, information from the
study will provide an understanding of which interventions to focus on during the SDGs
period to achieve rapid mortality reduction among children under five years old. The defini-
tions of the interventions evaluated in this study are found in the LiST.
Missed opportunity tool modeling strategy
The MOT estimates lives saved by automatically scaling up interventions with coverage levels
below 90% to 90%, one intervention at a time. Interventions with coverage levels at or greater
than 90% are excluded. Interventions with the most lives saved are those likely to contribute to
lives saved/mortality reduction if their coverage levels are increased.
Study area
The study was conducted in Ghana, a country with stable democratic governance since 1992.
Healthcare expenditure in 2014 was 60 United States Dollars per capita [26]. Schieber, Cashin
[10] has documented that Ghana’s U5M rate is high compared to its high healthcare spending.
Related to this is Ghana’s slow progress made on under-five mortality during the period of the
Millennium Development Goals (MDGs) [6].
Study variables
Information in the LiST used were mortality rates (neonatal, infant, and under-five), cover-
age of interventions, stunting, wasting, and contraceptive prevalence. The outputs were
mortality rates (neonatal and under-five) and lives saved. Neonatal mortality rate is the
probability of dying within the first month of life. In contrast, under-five mortality is the
probability of dying between birth and exactly five years [3]. The interventions included
were iron intake, intermittent preventive treatment of malaria in pregnancy, tetanus toxoid
vaccine (neonatal tetanus protection), skilled delivery, clean postnatal care, early initiation
of breastfeeding, water connection in the home, time to improved water source, improved
sanitation and insecticide-treated net/indoor residual spraying. From the LiST, at baseline
(2008), the neonatal mortality rate was 31.2 deaths per 1,000 live births, while the under-5
mortality rate was 75.3 deaths per 1,000 live births. At the end line (2014), the neonatal mor-
tality rate was 26.6 deaths per 1,000 live births, while the under-5 mortality rate was 57.1
deaths per 1,000 live births in Ghana.
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PLOS ONE Contribution of child health interventions to under-five mortality decline in Ghana
Definition of some of the interventions
Caesarean delivery: percent of women requiring surgical intervention if indicated (emergency
caesarean birth for obstructed labour, uterine rupture, or foetal distress).
Complementary feeding: percent of 6–23-month-old children receiving minimum dietary
diversity (4+ food groups).
Case management of severe neonatal infection (sepsis/pneumonia): sum of the three lev-
els of case management for severe infection in the neonatal period: oral antibiotics, injectable
antibiotics, and full supportive care.
Full supportive care for neonatal sepsis/pneumonia: full supportive care for neonatal sep-
sis/pneumonia.
Artemisinin compounds for the treatment of malaria: percent of children treated within
48 hours of the onset of fever in malaria-endemic areas with an artmesinin-containing com-
pound (artemisinin-based combination therapy).
Data analysis
The default data of Ghana in the LiST was loaded into the tool, and the analyses done. First of
all, to assess the contribution of only interventions to mortality decline between 2008 and
2014, the baseline for the impact evaluation was set at 2008 and the end line in 2014. Then,
interpolation was done between 2008 and 2014 (linear scale-up of coverage of interventions
between the baseline and end-line), and lives saved by interventions between 2008 and 2014
were reported. Finally, changes were made to this configuration (modeling strategy) to allow
for estimates of lives saved, and mortality rate reduced based on the direct entry of stunting
and wasting (reduction in the prevalence of stunting and wasting between 2008 and 2014) in
addition to the interventions. Lives saved due to changes in intervention coverage and differ-
ences in the prevalence of stunting and wasting were reported.
Secondly, to assess the interventions with the most potential to reduce mortality if coverage
levels were scaled up individually to 90% from the 2014 coverage levels, a new projection was
created with 2014 as the baseline and 2019 (a minimum of 5 years is allowed to estimate impact
using the LiST) the end line. The 2014 baseline projection was then uploaded into the missed
opportunity tool, and lives saved by each intervention were reported. All analyses were done
in duplicates, and the results were the same.
Lastly, for the analysis to assess the impact of interventions at scale-up of coverage levels to
100% in 2014, the projection created with 2008 as the baseline and 2014 as the end line was
used. Next, all the coverage levels of interventions with available data in 2014 were changed to
100%, interpolation done and lives saved, mortality reduction and neonatal and under-five
mortality rates reported. One hundred percent (100%) was chosen because coverage levels of
DPT, pneumococcal, rotavirus, and measles vaccines in the LiST were over 90%.
Ethics issues and consent to participate. Publicly available data was used, and the study
did not involve human subjects since secondary data was used.
Results and discussion
Results
A total of 48,084 lives were saved (Table 1), resulting from changes in coverage levels of inter-
ventions, and reduced stunting and wasting among children born between 2003 and 2014. In
addition, modeling involving only the interventions resulted in 34,477 lives saved/additional
deaths prevented.
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PLOS ONE Contribution of child health interventions to under-five mortality decline in Ghana
Table 1. Additional child lives saved and mortality reduction by intervention between 2008 and 2014 among children 0–59 months.
Interventions Lives saved
Pregnancy Baseline (2008) End line (2014) Coverage Intervention based Direct entry of stunting
coverage coverage change modeling and wasting
Tetanus toxoid vaccination (TT) 86.0 88.0 2.0 95(0.3) 95(0.2)
Prevention of malaria in pregnancy 43.7 67.5 23.8 810(2.3) 777(1.6)
Syphilis detection and treatment 23.6 24.0 0.4 4(0.0) 4(0.0)
Prevention of mother-to-child transmission of HIV 0.0 23.3 23.3 1,445(4.2) 1,446(3.0)
(including breastfeeding choices) (PMTCT)
Maternal age and birth order 2(0.0) 2(0.0)
Childbirth
Clean birth environment 46.8 59.9 13.1 736(2.1) 736(1.5)
Immediate drying and additional stimulation 52.3 66.9 14.6 809(2.3) 808(1.7)
Thermal protection 56.5 72.2 15.8 1,205(3.5) 1,205(2.5)
Clean cord care 54.5 69.7 15.2 1,318(3.8) 1,318(2.7)
Antibiotics for preterm or prolonged premature rupture of 42.7 54.7 11.9 320(0.9) 320(0.7)
the membranes (PROM)
Parenteral administration of antibiotics 42.7 54.7 11.9 320(0.9) 320(0.7)
Assisted vaginal delivery 14.4 18.5 4.0 439(1.3) 439(0.9)
Neonatal resuscitation 31.4 40.2 8.8 988(2.9) 988(2.1)
Caesarean delivery 48.3 76.4 28.1 4,145(12.0) 4,145(8.6)
Breastfeeding
Age-appropriate breastfeeding practices 60.6 50.0 -10.6 -1,711(-5.0) -1,786(-3.7)
Preventive
Change in stunting prevalence 27.5 18.8 8.7 NA 4,315(9.0)
Vitamin A supplementation (2 doses) 24.0 23.0 -1.0 -21(-0.1) -21(0.0)
Basic sanitation 12.7 16.5 3.8 120(0.3) 115(0.2)
Point-of-use filtered water 0.9 0.8 -0.1 -7(0.0) -7(0.0)
Piped water 39.4 35.3 -4.2 -191(-0.6) -190(-0.4)
Handwashing with soap 0.0 40.9 40.9 249(0.7) 234(0.5)
Insecticide-treated net/indoor residual spraying (ITN/IRS) 41.7 70.9 29.2 6433(18.7) 6437(13.4)
Complementary feeding 42.5 24.4 -18.1 394(1.1) NA
(via reduction in stunting)
Complementary feeding 42.5 24.4 -18.0 428(1.2) NA
(via reduction in wasting)
Vaccines
Diphtheria, pertussis, and tetanus (DPT) vaccine 88.0 98.0 10.8 869(2.5) 870(1.8)
Haemophilus influenzae type B 88.0 98.0 10.8 244(0.7) 243(0.5)
Pneumococcal vaccine (3 doses) 0.0 99.0 99.0 3,931(11.4) 3,938(8.2)
Rotavirus vaccine (3 doses) 0.0 98.0 98.0 655(1.9) 669(1.4)
Measles vaccine (1 dose) 89.8 92.0 5.4 239(0.7) 226(0.5)
Curative after birth
Case management of neonatal sepsis/pneumonia 57.1 73.1 16.0 4,271(12.4) 4,271(8.9)
Oral rehydration salts (ORS) 44.5 48.6 4.1 985(2.9) 917(1.9)
Antibiotics for treatment of dysentery 46.4 42.2 -4.0 -116(-0.3) -118(-0.2)
Zinc for treatment of diarrhoea 1.8 7.4 5.6 223(0.6) 208(0.4)
Oral antibiotics for pneumonia 50.7 52.6 1.9 422(1.2) 396(0.8)
Vitamin A for treatment of measles 24.0 23.0 -1.0 -9(0.0) -9(0.0)
Artemisinin-based combination therapy (ACTs) (within 11.3 26.2 14.9 4,322(12.5) 4,325(9.0)
48hours)
Treatment for severe acute malnutrition (SAM) 0.0 2.7 2.7 37(0.1) 0(0.0)
(Continued)
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PLOS ONE Contribution of child health interventions to under-five mortality decline in Ghana
Table 1. (Continued)
Interventions Lives saved
Pregnancy Baseline (2008) End line (2014) Coverage Intervention based Direct entry of stunting
coverage coverage change modeling and wasting
Change in wasting prevalence 8.6 4.7 3.9 NA 10,372(21.6)
Cotrimoxazole 2.7 4.1 1.4 31(0.1) 31(0.1)
ART for children 7.4 22.7 15.2 43(0.1) 45(0.1)
Total 34,477(100) 48,084(100)
https://doi.org/10.1371/journal.pone.0267776.t001
Interventions that saved the most lives considering the effect of reduction in the prevalence
of stunting and wasting among children under-five years were ITN/IRS, 6,437 (13.4%) lives
saved, ACTs, 4,325 (9.0%) lives saved, case management of neonatal sepsis/pneumonia, 4,271
(8.9%) lives saved, caesarean delivery, 4,145(8.6%) lives saved, and pneumococcal vaccine,
3,938 (8.2%) lives saved (Table 1). Reduction in wasting saved 10,372 (21.6%), while a decrease
in the prevalence of stunting also saved 4,315 (9.0%) lives. On the contrary, breastfeeding,
-1,786(-3.7.0%), piped water, -190 (-0.4%), antibiotics for treatment of dysentery, -118 (-0.2%),
and vitamin A supplementation, -21 (-0.0%) resulted in negative lives saved (excess deaths/
additional deaths) between 2008 and 2014 (Table 1).
If coverage levels of interventions in 2014 were scaled-up to 90% in 2015, each intervention
at a time, full supportive care for prematurity (5,435 lives saved), full supportive care for neo-
natal sepsis/pneumonia (3,002 lives saved), assisted vaginal delivery (2,163 lives saved) and
kangaroo mother care (2,010 lives saved) would have saved the most lives among neonates
(Table 2). In addition, ACTs (4,925 lives saved), ORS (2,056 lives saved), antibiotics for the
treatment of pneumonia (1,805 lives saved), and prevention of mother-to-child transmission
of HIV (including breastfeeding choices) (1,020 lives saved) would have made the most impact
on mortality reduction among children 1–59 months (Table 2).
Also, if coverage levels of all the interventions were scaled up to 100% in 2014, the neonatal
mortality rate would have been 21.7 deaths per 1,000 live births instead of 26.2 deaths per
1,000 live births, while the U5M rate would have been 40.1 deaths per 1,000 live births instead
of 57.1 deaths per 1,000 live births in 2014. Under this scenario (coverage of interventions at
100%), results from the effect of only interventions showed that ACTs, 21,204 (19.6%), ITN/
IRS, 12,906 (11.9%), oral antibiotics for pneumonia, 9,173 (8.5%) and age-appropriate breast-
feeding practices, 7,935 (7.3%) would have contributed the most to mortality reduction
(Table 3).
Discussion
Ghana failed to achieve the MDG4 target despite efforts at increasing intervention coverage
levels. This study, therefore, evaluated the contribution of the various interventions to mortal-
ity decline. Information from the study will help prioritize intervention scale-up. Reduction in
the prevalence of wasting and stunting, malaria control interventions (ACT and ITN/IRS),
pneumococcal vaccines, and childbirth-related interventions (case management of neonatal
sepsis/pneumonia, caesarean delivery, clean cord care, and thermal protection) caused mortal-
ity reduction. In contrast, nutrition (breastfeeding, vitamin A supplementation, and vitamin A
for the treatment of measles) and water-related (piped water and point-of-use filtered water)
interventions were responsible for excess mortality between 2008 and 2014.
Proper maternal and child nutrition plays a crucial role in child survival. It reduces the risk
of important causes of death such as malaria, diarrhoea, and pneumonia [6,7] and risk factors
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Table 2. Lives saved at 90% intervention coverage level, one intervention at a time among children 0–59 months.
Intervention Baseline coverage Total additional deaths prevented
0–1 months 1–59 months
Full supportive care for prematurity 0.0 5,435 0
Artemisinin compounds for treatment of malaria (ACT) 26.2 0 4,925
Full supportive care for neonatal sepsis/pneumonia 0.0 3,002 0
Assisted vaginal delivery 18.5 2,163 0
Oral rehydration solution (ORS) 48.6 64 2,056
Kangaroo mother care (KMC) 0.0 2,010 0
Oral antibiotics for pneumonia 52.6 0 1,805
Neonatal resuscitation 40.2 1,582 0
Injectable antibiotics for neonatal sepsis 73.1 1,382 0
Prevention of mother-to-child transmission of HIV (including breastfeeding choices) (PMTCT) 23.3 0 1,020
Households protected from malaria (ITN/IRS) 70.9 0 999
Multiple micronutrient supplementation in pregnancy 0.0 871 18
Treatment for moderate acute malnutrition (MAM) 0.0 0 849
Point-of-use filtered water 0.8 22 781
Zinc supplementation 0.0 0 785
Zinc for the treatment of diarrhoea 7.4 20 642
Oral antibiotics for neonatal sepsis 0.0 655 0
Cesarean delivery 76.4 653 0
Breastfeeding promotion 50.0 93 511
Clean cord care 69.7 515 0
Piped water 35.3 14 497
Cotrimoxazole 4.1 0 485
Clean birth environment 59.9 454 0
Basic sanitation 16.5 12 437
Thermal protection 72.2 398 0
Immediate drying and additional stimulation 66.9 360 0
Vitamin A supplementation 23.0 0 304
Treatment for severe acute malnutrition (SAM) 2.7 0 289
Antibiotics for preterm or prolonged premature rupture of the membranes (PROM) 54.7 265 0
Parenteral administration of antibiotics 54.7 265 0
Antibiotics for treatment of dysentery 42.4 7 239
Prevention of malaria in pregnancy 67.5 223 15
Antiretroviral therapy (ART) 22.7 0 236
Appropriate complementary feeding 24.4 0 219
Syphilis detection and treatment 24.0 219 0
Folic acid fortification 0.0 207 0
Calcium supplementation 0.0 186 1
Handwashing with soap 40.9 4 128
Balanced energy supplementation 0.0 61 2
Vitamin A for treatment of measles 23.0 0 32
Tetanus toxoid vaccination (TT) 88.0 21 0
Measles vaccine 92.0 0 2
https://doi.org/10.1371/journal.pone.0267776.t002
such as preterm, small for gestational age, stunting, and wasting [3,27]. Unfortunately, breast-
feeding and complementary feeding prevalence reduced between 2008 and 2014 among chil-
dren under-five years in Ghana [3,28]. This resulted in -1,786 (-3.7%) excess deaths due to a
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PLOS ONE Contribution of child health interventions to under-five mortality decline in Ghana
Table 3. Additional child lives saved by intervention in 2014 intervention coverage levels were scale-up to 100%
among children 0–59 months.
Intervention Coverage increased from Lives saved
baseline to 100% (%)
Tetanus toxoid vaccination (TT) 14.0 669(0.6)
Prevention of malaria in pregnancy 56.3 1,896(1.7)
Syphilis detection and treatment 1.1 15(0.0)
Prevention of mother-to-child transmission of HIV (including 100.0 1,450(1.3)
breastfeeding choices) (PMTCT)
Maternal age and birth order 2(0.0)
Childbirth
Clean birth environment 35.2 1,850(1.7)
Immediate drying and additional stimulation 39.3 2,078(1.9)
Thermal protection 42.4 3,026(2.8)
Clean cord care 40.9 3,041(2.8)
Antibiotics for preterm or prolonged premature rupture of the 32.1 836(0.8)
membranes (PROM)
Parenteral administration of antibiotics 32.1 836(0.8)
Assisted vaginal delivery 10.8 1,104(1.0)
Neonatal resuscitation 23.6 2,511(2.3)
Parenteral administration of uterotonics 38.3 0(0.0)
Cesarean delivery 51.7 7,134(6.6)
Breastfeeding
Age-appropriate breastfeeding practices 50.0 7,935(7.3)
Preventive
Vitamin A supplementation 76.0 1,247(1.2)
Basic sanitation 87.3 1,992(1.8)
Point-of-use filtered water 99.1 5,560(5.1)
Piped water 60.6 2,140(2.0)
Handwashing with soap 100.0 387(0.4)
Hygienic disposal of children’s stools 57.6 0(0.0)
Households protected from malaria (ITN/IRS) 58.3 12,906(11.9)
Complementary feeding (via reduction in stunting) 57.5 1,361(1.3)
Complementary feeding (via reduction in wasting) 57.5 464(0.4)
Vaccines
DPT vaccine 12.0 882(0.8)
Haemophilus influenzae b vaccine 12.0 222(0.2)
Pneumococcal vaccine (3 doses) 100.0 3,433(3.2)
Rotavirus vaccine (3 doses) 100.0 416(0.4)
Measles vaccine (1 dose) 10.2 970(0.9)
Curative after birth
Case management of neonatal sepsis/pneumonia 16.0 3,617(3.3)
Oral rehydration solution (ORS) 55.5 4,911(4.5)
Antibiotics for treatment of dysentery 53.6 540(0.5)
Zinc for the treatment of diarrhea 98.2 1,438(1.3)
Oral antibiotics for pneumonia 49.3 9,173(8.5)
Vitamin A for treatment of measles 76.0 237(0.2)
Artemisinin compounds for the treatment of malaria (ACT) 88.7 21,204(19.6)
Treatment for severe acute malnutrition (SAM) 100.0 830(0.8)
Cotrimoxazole 97.3 31(0.0)
Antiretroviral therapy (ART) 92.6 46(0.0)
Total 108,390(100)
https://doi.org/10.1371/journal.pone.0267776.t003
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PLOS ONE Contribution of child health interventions to under-five mortality decline in Ghana
reduction in breastfeeding (60.6% to 50%) between 2008 and 2014. Despite this, a decline in
stunting (28.0% to 18.8%) and wasting (8.5% to 4.7%) was achieved between 2008 and 2014,
contributing to a 9.0% and 21.6% mortality reduction, respectively. The food fortification pro-
gramme with vitamin A, the Livelihood Empowerment Against Poverty (LEAP) programme
introduced in 2007, the school feeding programme introduced in the 2005–2006 academic
year [29], and poverty reduction during the period of evaluation could explain the decrease in
stunting and wasting despite a reduction in the prevalence of complementary feeding [3,28]. It
implies that further mortality decline can be achieved if complementary feeding and breast-
feeding coverage levels are increased. Similar results of reducing stunting and wasting to mor-
tality decline have been reported [13,30–32].
Generally, negative lives are saved if the coverage level of an intervention is reduced during
the evaluation period. This means taking the population that needed to be protected by the
intervention, the percentage protected was less at the end line than the baseline. Therefore, a
proportion of the people became unprotected and died as a result. It could be the case that the
intervention is available but not all the population that needs it uses it. Examples of such inter-
ventions are breastfeeding, vitamin A supplementation and antibiotics to treat dysentery. The
negative lives saved could also be due to an increase in the population size not matched with
the scale-up of the intervention. This could be the case with piped water. Population growth is
not commensurate with the provision of piped water.
Malaria remains a top cause of under-five deaths in Ghana, and therefore, effective inter-
ventions targeting malaria deaths should have a high impact. While household ITN/IRS cover-
age made a substantial impact (15% mortality reduction), they still have the potential for
increased impact if coverage is scaled up. Similar results of the effect of bed net on mortality
have been documented [13,17,30,33]. Comparing ACTs to ITN/IRS, ACTs also saved many
lives (9% reduction in mortality rate), but this was lower than that achieved by ITN/IRS
(13.4% reduction in mortality rate). This is likely due to the low coverage change of ACTs
(11.3% to 26.6%) between 2008 and 2014 compared to ITN/IRS (41.7% to 70.9%). This low
coverage could explain the continuously enormous contribution of malaria to U5M and the
generally low mortality decline in Ghana since uncomplicated malaria can progress rapidly to
severe disease and death due to delay in treatment. It also implies that ACT can save additional
lives since its current coverage level is low in the country. Therefore, it should be one of the
interventions to focus on to further reduce mortality, especially in malaria high burdened
regions of Ghana.
Vaccines have historically, and in recent times, contributed greatly to mortality reduction
[17,30,31,34]. In this study, pneumococcal and rotavirus vaccines greatly impacted mortality
reduction, 8% and 3%, respectively. These vaccines are relatively new, were introduced in
2012, accounting for their high coverage level change, 0 to 99% for pneumococcal vaccine and
0 to 98% for rotavirus vaccine between 2008 and 2014 [3,8]. However, they are not likely to
save more lives than their current impact in the future, just like the old vaccines. This is
because, with a national level coverage of over 90% for most vaccines, any further increase in
coverage will be less than 10%. Also, if the high coverage levels of these vaccines reduce the
prevalence of vaccine-preventable diseases in the population like diphtheria and tetanus, they
will likely not contribute greatly to mortality decline even if their coverage levels are further
increased since very few children will suffer from these conditions. Considering that one of the
most effective tools for reducing mortality does not have much potential for further mortality
reduction, coverages of other high-impact interventions, especially those with low coverage
levels need to be increased. The recently introduced malaria vaccine might contribute to filling
this gap [9].
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PLOS ONE Contribution of child health interventions to under-five mortality decline in Ghana
In this study, interventions related to childbirth, such as caesarean delivery delivered by
skilled personnel, contributed the most to lives saved (8.6% of lives saved). Skilled delivery is
one of the main strategies to reduce neonatal mortality, an important contributor to U5M. In
Tanzania, skilled delivery and emergency obstetric care among neonates contributed to a 29%
(6,200 lives saved) reduction in mortality between 2000 and 2012 [30]. However, Ethiopia
achieved the MDG4 target on child survival with skilled delivery coverage between 2000 and
2011 of less than 5%, contributing to a 3% decline in U5M [31]. The quality of skilled delivery
has been questioned, and neonatal mortality ranked second in deaths due to poor quality of
care [35].
In Ghana, while the coverage level of skilled delivery was 84.3% in 2008 and 92.1% in 2014
in the Greater Accra Region, neonatal mortality increased from 21 deaths per 1,000 live births
to 25 deaths per 1,000 live births between 2008 and 2014. Also, in the Ashanti Region, skilled
delivery coverage was 72.6% in 2008 and 86.3% in 2014; still, the region recorded an increase
in neonatal mortality from 35 deaths per 1,000 live births to 42 deaths per 1,000 live birth from
2008 to 2014 [3,28]. On the contrary, in the Upper West Region, where the skilled delivery cov-
erage level was 46.1% in 2008 and 63.7% in 2014, neonatal mortality decreased from 45 deaths
per 1,000 live births to 24 deaths per 1,000 live births between the periods. Likewise, in the
Northern Region where skilled delivery coverage was 27.2% in 2008 and 36.4% in 2014, neona-
tal mortality declined from 35 deaths per 1,000 live births to 24 deaths per 1,000 live births
within the period [3,28].
The trajectory of under-five mortality in Ghana. In 2014, if coverage levels of all the
interventions were scaled up to 100%, the neonatal mortality rate would have declined from
31.2 deaths per 1,000 live births to 21.7 deaths per 1,000 live births, while the U5M rate would
have declined from 75.3 deaths per 1,000 live births to 40.1 deaths per 1,000 live births.
Although this would have been daunting and impossible to achieve, Ghana would have
achieved the MDGs target of an under-five mortality rate of at most 40 deaths per 1000 live
births. However, any further rapid decrease in mortality will be impossible once the coverage
levels of most interventions reach 100%. This suggests that the available packages of care
remain suboptimal even if they were taken to 100% coverage; hence, the need to continue
innovating in alternative complementary interventions. This situation is consistent with the
documented slow decline in child mortality in Ghana [6]. This slow decline could mean that
the interventions implemented are not producing the needed reduction in mortality, and the
quality of the interventions could be the cause [35,36].
If this trend persists, Ghana will not achieve the SDGs targets of neonatal mortality of 12
deaths per 1,000 live births and U5M of 25 deaths per 1,000 live births as already projected [4].
The mortality rate will likely be stagnant, as observed among regions in Ghana with historically
low under-five mortality rates [3]. Historically, vaccines have contributed greatly to mortality
reduction, but future mortality decline is unlikely due to their current high (over 90%) cover-
age levels [3]. Therefore, most vaccines are not part of the interventions evaluated that can fur-
ther reduce mortality in Ghana. Also, neonatal mortality contributes greatly to U5M. From
assessing the interventions that can further reduce neonatal mortality if coverage levels were
increased, interventions that operate at childbirth related to skilled delivery are the most
important. Unfortunately, access to quality skilled care remains a challenge. It, therefore, sug-
gests that rapid mortality decline will only be possible if there is an increase in coverage and
quality of the few high-impact interventions related to nutrition, water, hygiene and
childbirth.
On study limitations and strengths, LiST assumes constant effectiveness of interventions
that might not always hold because several factors, including the quality of the interventions
and their implementation, could affect interventions when implemented under real-life
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PLOS ONE Contribution of child health interventions to under-five mortality decline in Ghana
conditions [37]. Furthermore, data is not available for some interventions in LiST, and
assumptions are made on these. However, validation studies show that LiST produces reliable
estimates based on the information available. Additionally, the LiST assumes that distal factors
like household factors such as wealth, maternal education, and place of residence affect mortal-
ity through interventions that might be problematic [23]. Validation studies have been per-
formed, and the tool has been found to work well [15,16,18,38–41]. Lastly, this analysis used
only data contained in the LiST, and it did not consider the feasibility of the scale-up scenarios
created.
In conclusion, this study assessed the impact of interventions on under-five mortality.
Insecticide-treated net/indoor residual spraying, ACT, pneumococcal vaccine, rotavirus vac-
cine, skilled delivery, and reduction in stunting and wasting made the most impact on mortal-
ity among children born between 2003 and 2014 in Ghana. Childbirth-related interventions,
ITN/IRS, ACT, and water and sanitation interventions would have made the most impact if
the 2014 coverages of interventions were scaled up to 90% in 2015. Despite the potential
impact of the current package of interventions, if coverage levels are increased, this increase
might not rapidly reduce mortality. Avenues to reduce stunting and wasting, including
increasing breastfeeding and complementary feeding, will be beneficial. Mothers and caregiv-
ers should be encouraged to provide balanced diets for their children. Together with the Min-
istry of Health and Ghana Health Service, the Ministry of Education should ensure that meals
provided under the school feeding programme are balanced diets.
Supporting information
S1 Table. All interventions used in the modeling.
(DOCX)
S2 Table. Interventions that were scaled up to 100%.
(DOCX)
Author Contributions
Conceptualization: Augusta Kolekang, Bismark Sarfo, Anthony Danso-Appiah, Duah Dwo-
moh, Patricia Akweongo.
Formal analysis: Augusta Kolekang, Duah Dwomoh.
Supervision: Patricia Akweongo.
Writing – original draft: Augusta Kolekang.
Writing – review & editing: Augusta Kolekang, Bismark Sarfo, Anthony Danso-Appiah,
Duah Dwomoh, Patricia Akweongo.
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