Managing Malaria in Pregnancy Policy Interventions in A Challenging Environment: an Ethnographic Study of two Ghanaian Administrative Regions


 Background: Malaria in pregnancy (MiP) is an important public health problem across sub Saharan Africa. Regular use of Long-Lasting Insecticide treated bed Nets (LLINs), directly observed administration (DOT) of intermittent preventive treatment with sulphadoxine-pyrimethamine (IPTp-SP) and prompt and effective case management of MiP has constituted the package of measures for its control in Ghana in the last 20 years. Unfortunately, Ghana like other sub Saharan African countries did not achieve the reset Abuja targets of 100% of pregnant women having access to IPTp and 100% use of LLINs by 2015. Methods: This ethnographic study explored how managers dealt with existing MiP policy implementation and arrangement challenges and the consequences on clients’ access to MiP interventions, using observations with conversations, in-depth interviews and case studies in eight health facilities and twelve communities for twelve months, in two Administrative regions in Ghana. The University of Health and Allied Sciences’ Research Ethics Committee approved the study [UHAS-REC/A.I Ul 17-18]. Results: Managers addressed frequent stock outs of malaria programme drugs and supplies from the National Malaria Control Programme and delayed reimbursement from the NHIS, by instituting co-payment, rationing drugs and relaxing the DOTs policy. This ensured that facilities had funds to pay creditors, purchase drugs and supplies in order to ensure continued service delivery. Clients who could afford the cost of maternal and MiP services and those who had previously benefitted from such services were happy to access uninterrupted services. Whilst clients who could not afford the cost of services resorted to health care shopping, delaying in starting ANC and skipping scheduled ANC visits. Consequently, some clients did not receive the recommended five+ doses of SP, others did not obtain LLINs early and some did not obtain recommended treatment for MiP. Frontline workers felt frustrated and demotivated, because sometimes they could not provide comprehensive care to clients who could not afford it. Conclusion: For Ghana to achieve her goal of controlling MiP, the Ministry of Health and other supporting institutions need to ensure prompt reimbursement of funds, the supply of programme drugs and medical supplies to public, faith based and private health facilities.

Despite such interventions Ghana like other sub Saharan African countries did not achieve the reset Abuja targets of achieving 100% of pregnant women having access to IPTp and 100% use of LLINs by Mintzberg (35), de nes power in organizations as "…the capacity to effect (or affect) organizational outcomes." How health managers and workers exercise power in everyday decisions on health care shapes health facilities' internal policies, which determine the quality of health care that clients experience (37)(38)(39)(40)(41). Managers are expected to exercise power in the implementation of policies that contribute to the achievement of organizational goals (42,43). Managers' sources of power include authority vested in the o ce of the manager, networks and access to resources (44,45). Frontline health workers such as nurses, doctors, pharmacists and laboratory technicians exercise power in delivering health care to clients. Their sources of power include their knowledge, expertise, skills and access to the clients who utilize health services (35,40,44,45).
When power is exercised positively, clients develop trust in health providers and the health care system. Where power is exercised negatively clients distrust health providers (41,46). Trust has been de ned as "…the optimistic acceptance of a vulnerable situation in which the trustor believes the trustee will care for the trustor's interests" (36). Effective health care requires a social relation of trust between health providers and clients. Trust directly affects the attitudes and behaviors of clients in decisions on health care (36,(47)(48)(49). When clients perceive negative exercise of power in health facilities, they respond by nding alternative sources of health care, refusal to comply with scheduled visits and failure to adhere to treatment. However, when power is exercised positively, clients develop trust in health providers and patronize health services and adhere to treatment. Health manager -worker trust relations has equally been explored (50). When health managers provide the needed resources for health care provision, health workers are able to exercise power positively, by providing quality health care, which enhances their trust in managers. When managers fail to meet workers' work needs, they lose trust in managers and become demotivated in the provision of health care (46,50,51).

Selection of research area
The study was conducted in ve districts, three in the Ashanti and two in the Volta regions of Ghana. Eight health facilities: ( ve government and three faith-based) and twelve communities were chosen for the study. A three-stage selection process was used: (i) ve districts were selected ii ; (ii) the district hospitals in the ve districts automatically quali ed to participate in the study; (iii) the study team visited the hospitals and went through ANC case records. The total number of MiP cases from January, 2015 to March, 2018, in each community were recorded and the community with the highest recorded number of malaria in pregnancy cases in each facility was chosen to participate in the study. Information on communities that each facility served was obtained from the o ces of the study districts' health directorate. Most of the communities had an average population of 10,000. One of the districts in the Volta region had communities with an average of 2,000 inhabitants, so six communities with the highest number of malaria in pregnancy cases were combined to form two large communities (Table 1). A sensitization workshop was held by the research team for the Volta Regional health directorate and the district health management teams (DHMT) of the participating districts in the Volta region. The regional health director and the directors of the DHMTs approved the study. A sensitization workshop was not carried out in the Ashanti region, because some of the team members in the current study had previously conducted studies in malaria in the same districts and already had established a relationship with the region and districts. Nevertheless, letters were sent to the participating districts health directorates in the Ashanti and Volta regions. The various districts gave written approval for the study. Copies of the approval letters were sent to the participating hospitals and communities to seek permission from the senior medical o cers responsible for the hospitals and the chiefs and assembly members of the study communities. Additional letters had to be written to the administrators of the three faith-based facilities before approval was obtained. Community sensitization was done, paying courtesy calls on assembly members and chiefs and holding meetings with a cross section of opinion leaders to inform and seek their permission to conduct the study in their communities. Interactions and interviews with pregnant women revealed that in some communities speci c health facilities were preferred for ANC services.
Three of such facilities, which are faith-based were included. Also transect walks were carried out in the study communities to identify key places and physical accessibility to health care facilities.

Selection of study participants
A research assistant carried out observations in a health facility and interacted with the pregnant women who attended ANC. The study was explained to them and those who were interested voluntarily offered written consent to participate in the study. Pregnant women were also recruited from the study communities, using the snowball method. The rst pregnant woman to be identi ed helped the RA to identify others.
Case studies were purposively selected among women attending ANC every month and those who were irregular or skipped their ANC appointments. The RAs visited them at home, for observations and conversations. ANC providers who had been working in a facility for at least one year, majority of whom were midwives, participated in the study. Conversations were conducted with procurement o cers, laboratory personnel and o cials at the district health directorate, to clarify some of the issues raised on LLINS in IDIs with health providers and health managers. ANC unit managers commonly referred to as incharge, facility managers such as senior medical o cers, physician assistants and administrators, were interviewed, to help understand managerial and administrative issues. Visits were made to some of the districts of the national health insurance scheme (NHIS), to converse with some staff members.
Conversation was also held with one of the national deputy directors of the scheme, to clarify and verify issues raised by health managers such as delays in reimbursement, legality of charges for some ANC and MiP services ( Table 2).

Data analysis
Interviews were tape recorded and transcribed verbatim to preserve interviewees' original messages. Interviews in Ewe and Twi were transcribed into English to enable easy analysis and comparison. This study was conducted as part of a larger study on parasitic infections during pregnancy and community interventions programme in Ghana. The study set out to explore socio-cultural and community factors in uencing the utilisation of MiP interventions in Ghanaian communities. However, the initial analysis revealed that multiple community and health system factors in uenced utilisation of MiP interventions. This informed the team to return to the study health facilities to explore and understand health system factors in uencing MiP service provision.
A grounded theory approach was used in data analysis (53). The rst set of data (interviews, observation notes and conversations) was triangulated and an iterative approach was used to code the data, with the assistance of qualitative analysis software, Nvivo Version 11. Key informants such as managers and health workers were visited for further interviews in pursuance of the emerging themes. The coding, analysis and data collection went on until saturation was attained. The emerging themes formed the basis of presentation of ndings.

Ethical issues
Ethical clearance was obtained from the University of Health and Allied Sciences' Research Ethics Committee [UHAS-REC/A.I . Written consent was obtained from all interview participants, while verbal consent was obtained from conversation participants vii . Permission was obtained from district directors of health, facility and ward managers. To protect informants' identity, besides actual country and region names, individuals and facilities' names used in this article are pseudonyms.

Managers' strategies in dealing with MiP implementation challenges
Managers and health workers exercised power in addressing challenges in MiP policy implementation arrangements such as frequent stock outs of malaria programme drugs and supplies from the National Malaria Control Programme (NMCP), delayed reimbursement from the NHIS and medical consumables from the Ministry of Health (MOH) as follows: 1. instituting co-payment for services that were previously free of charge such as SP and MiP tests, 2. rationing SP and sometimes relaxing the DOT policy, 3. prescribing drugs, which were previously issued under the NHIS for clients to buy from the open market ( Fig. 1). The facilities adopted such coping strategies to ensure that they always had funds to purchase essential medical supplies and drugs, to pay casual laborers and suppliers, in order to sustain service provision.
Resultantly, some clients could not afford the cost of accessing MiP and maternal health services. They resorted to health care shopping, skipping scheduled visits and some started ANC late, which affected access to LLINs, SP intake and adherence to MiP treatment. Clients' expectations of comprehensive MiP was not met, resulting in loss of trust in health providers. Nevertheless, a few clients who could afford the cost of services appreciated the seamless ow of services. However, some health workers felt frustrated, demotivated and lost trust in managers in facilities that were not buying and selling medical products to clients and thus could not afford to buy all the needed medical supplies that workers required to carry out effective health care services. The different issues are further discussed below.
How health facilities dealt with challenges in MiP policy implementation arrangement Managers and health workers reported in interviews that the National Malaria Control Programme (NMCP) provides both government and faith-based facilities with malaria programme drugs and supplies such as SP, malaria test kits (RDT) and LLINs through the Central Medical Stores (CMS) and the district health directorate (ASFacility01, IDI, Facility Manager; VRFacility02, IDI, Facility Manager). They indicated that they frequently experience stock out of SP from the CMS and they are no longer being supplied with RDTs. However, they had experienced relatively few occasions of stock outs of LLINs from the NMCP. A general stock out was experienced in December 2018 and January 2019, which was as a result of a national mass distribution. Extensive discussion on this issue can be found in another paper (54).
Managers in ASFacility02, ASFacility03 and ASFacility04 in the Ashanti region reported that they decided to use internally generated funds (IGF) to procure SP from private manufacturing companies, whenever there was stock out. To recoup their money, they instituted co-payment dubbed 'top up', where SP, which was previously free of charge, was sold to clients. However, they added that whenever the facilities get SP from the CMS, it is given to pregnant women for free. Two study participants commented: "We were giving the drug [SP] to pregnant women for free when the government used to provide the SP. But because the facility buys the drug [SP] from its internally generated funds (IGF), it will de nitely come at a cost to pregnant women." (ASFacility04, Conversation, Supply O cer, 20/05/2018).
"The district health directorate used to supply us with the SP. The district health directorate no longer supplies us with the SP. Sometimes, we go to the district pharmacy for the SP, but it is not forth coming, so I bought this one (pointing to a box containing SP on the table in the ANC consulting room) from outside market to avert stock out of the SP." (ASFacility02, IDI, ANC manager) The four study facilities in the Volta Region and one facility in the Ashanti region did not buy SP from the open market, so they run out of stock whenever they were not supplied SP, as a manager explained: "For medicines, those that we are supposed to get from the open market are always available, but the programme drugs like the SP…if it is not available at the District Medical Store or Regional Medical store, we cannot get it from anywhere. Sometimes it [unavailability of SP] affects our clients." (ASFacility01, IDI, Facility manager 01). Other times clients were told that there was no SP and they were not given alternatives. Some of the facilities issued prescriptions to ANC attendees to buy SP from private outlets. Thus, such facilities could not enforce DOT on such occasions. However, some of the health providers in ASfacility02 and VRfacility04 compelled ANC attendees to return to the facility to take the purchased SP under DOT, by seizing their maternity records booklets, which was only given back to them, after they had returned to take the purchased SP under DOT.
VRFacility02 dealt with stock out of SP by asking clients to go and return at a later date. Some clients returned after a week or more and obtained SP (VRFacility02, Observation notes, 02/07/2019). Another strategy was to borrow SP from other sister government health facilities (VRFacility02, IDI, Facility manager). ASFacility04 dealt with stock outs by rationing SP to clients, such that some clients ended up taking 3 doses of SP by the time of delivering, instead of 5 or more.
Facilities used part of their IGF to buy RDT kits and reagents, so they charged fees in order to recoup the money. Thus the policy of fee free testing for malaria in pregnancy service was changed to a fee paying service.
In three facilities in the Ashanti Region clients paid for anti-malarials such as artesunate-amodiaquine, however in some of the facilities in the Volta Region such as VRFacility04, it was given to women free of charge. Managers explained that they were not readily available, so they had to buy them from the open market and sell them to clients. However quinine was administered free of charge.
Delayed reimbursement from the National Health Insurance Scheme and hidden cost of MiP and maternal health care impacting on access to MiP interventions Delays in reimbursement of the cost of services provided and in the provision of medical supplies and consumables contributed to facility management instituting fees for some consumables and services. Most of the fees were paid at the pharmacy and most clients were issued receipts. The institution of fees contributed to the increasing cost of ANC services.
The eight facilities explained that the NHIS frequently delays for over six months in reimbursing them for services that they provide. This assertion was con rmed by a senior o cial of the NHIS, who added that some facilities had only received reimbursement for services provided in early 2018 in 2019 (Conversation with a NHIA deputy director, Accra, 11/03/2019). Yet, managers had to service accumulating debts, buy drugs, pay contract staff and suppliers, buy and service equipment in order to keep their facilities functioning. So managers in all the facilities exercised power by instituting various forms of co-payment dubbed 'top up' for services that were previously free. Insured clients in three facilities in the Ashanti region paid half the price of routine drugs such as folic acid, ascorbic acid, fersolate and vitamin B complex, while uninsured clients paid the full cost (ASFacility02, Observation notes, 27/08/2018; ASFacility04, Observation notes, 16/08/2018; ASFacility03, IDI, Facility Manager). However, all the four facilities in the Volta Region offered routine drugs to ANC clients free in charge.
For clients to access fee free maternal health and MiP services, they had to undergo a urine in pregnancy test (UPT), which costs GH 5 (1$). NHIS reimburses facilities for services provided to NHIS registrants and since majority of the women, who attend ANC for the rst time are not insured, the facilities could not obtain reimbursement from the NHIS. The facilities thus passed this cost to the clients, as they could not afford to use their limited IGF to offer free UPT to the women. Health providers in interviews explained that a second reason for the mandatory pregnancy test was to prevent non pregnant women from exploiting the free maternal health care service (ASFaciility01, Conversation, Midwife, 19/11/2018; ASFaciility01, IDI, Facility Manager). Once women tested positive, they were registered on the NHIS and were expected to subsequently enjoy free maternal and MiP services.
In four facilities ANC clients paid 5GHS (1$) for a maternity record booklet. The facilities explained that maternity booklets were offered free of charge, when they were supplied by the MOH. However, the MOH had failed to supply any in the last six months. In some facilities before women were given their rst dose of SP, they were required to undertake a microscopic examination of blood for malaria parasites, utilising blood lms (BFF test), which cost 5 GH (1$).
Perceived negative in uences of strategies adopted by health facilities on maternal and MiP health seeking behaviour of clients Some women were happy to take the prescription forms, because once they left the hospital, the health workers ceased to have power to compel them to purchase the prescribed drugs. Sometimes such measures led to women visiting the same facility with the same complaints: "… those who want to buy will buy. Others will also leave the prescriptions in their ANC booklet and come with the same complaints on their next visit." (VRFacility02, IDI, Maternity Department Manager).
Some women waited till they were nearly due to deliver before attending ANC. So they did not receive LLINs and the mandatory ve doses of SP (ASFacility01, IDI, Health worker01). Others who had never attended ANC were informed by friends, acquaintances and relatives who had ever attended ANC that one had to make payments, which deterred them from starting ANC early. This contributed to late uptake of IPTp-SP and use of LLINs, as both are offered at the ANC clinics. An IDI with a pregnant 16 year old adolescent, who was seven months pregnant, but had never attended ANC revealed: Interviewer: "Why don't you go for ANC?" Adolescent: "I don't have money." Interviewer: "You said you haven't started ANC, so how did you know you pay money there?" Adolescent: "One of my sisters told me." Interviewer: "So if you had the money, would you have gone?" Adolescent: "Yes, as for the ANC it is good. When you go they give drugs." (ASCommunity03, IDI, Pregnant Woman 12) Several pregnant women who could not afford the cost of maternal health care services and those who were given prescriptions to purchase certain drugs from the open market, perceived that the health care system was not responsive to their health needs, thus they lost trust in it. Some engaged in health shopping such as visiting other health facilities when they were told that more drugs were being provided in those facilities. Others supplemented ANC visits with visits to prayer camps, herbal centres and some engaged in self-medication. A seventeen year old adolescent, who was six months pregnant explained to the research team that she skipped her last scheduled ANC visit, because she did not have money, yet she went to the prayer camp every Thursday. She shared her high trust in the prayer camps as follows: "The hospital will only see the physical and the best that they can do for you is to prescribe drugs for you to go and buy and take. But the prophet can see both physical and spiritual. After consultation, he would give you herbs to go and take and after three days you will be well. He can also foresee and avert any misfortune that can happen in the course of the pregnancy. So for me I trust the prophet more." Health providers perceived that clients distrusted them and believed that they bene tted from the payments. They perceived that was the reason for the reluctance towards any payment, as evidenced in a conversation with two midwives: "They think that we use the money for ourselves." (VRFacility04, conversation with two midwives, 29/08/2019) Health managers and workers felt frustrated that sometimes the women ended up buying the wrong drugs or were offered expired drugs by drug stores who exploited the women (VRFacility02, IDI, ANC Manager; VRFacility02, IDI, Facility Manager). An ANC manager lamented: 'You write for them to go and buy [drugs] and when they go they come back with another drug, so it's a serious thing (VRFacility02, IDI ANC Manager 01). Such actions compromised adherence to treatment.
Some health workers believed that the reason for the shortage of drugs and supplies was because the district health directorate, which they perceive has power to ensure their availability was not responsive to the facilities' needs. An ANC Manager expressed her frustration: …you know the routine drugs are not available all the time (folic acid, multivite and ferrox and iron capsules… It's a challenge, but unless the authority get up, because we have been complaining and since they [district health directorate] are not on the ground, I don't know if they don't feel the pain, but we do feel the pains of the pregnant women. You can't get up and do what you want to do, because they said all initiatives should come from the directorate (VRFacility02, IDI, ANC Manager).
Two ANC managers in VRFacility04, reported in interviews that they did not trust that their facility manager was responsive to health providers' needs for resources to work with. They believed that she did not always include the requisition for drugs and medical consumables made by the ANC to the DHA and the CMS.
Facility managers on the other hand explained that the stock outs and unavailability of medical supplies were a result of failure to reimburse facilities and delays from the CMS (VRFacility02, IDI, Facility Manager; VRFacility04, IDI, Facility Manager).

Discussion
Managers dealt with MiP policy intervention and arrangement challenges such as frequent stock outs, delayed reimbursement and procedures not were not reimbursable by instituting charges on services and drugs that were previously offered for free. Clients experienced direct cost of MiP services such as paying for SP and buying drugs that were previously given for free at health facilities. They also experienced indirect cost of MiP services such as paying for UPT test, BFF test and G6PD and scanning services to facilitate effective MiP and other maternal health services. Those who could not afford the cost delayed ANC visits, skipped ANC appointments and others defaulted or declined to access recommended laboratory tests. Thus, managers' initiative defeats the objective of MiP and maternal health policies, which aim at improving maternal health care by ensuring equity of access to all pregnant women. Nevertheless, women who could afford the cost of MiP and Maternal health care found the effective functioning of maternal health and MiP services worthwhile.
MiP policy interventions are offered as part of comprehensive ANC care. So hidden cost of maternal health care and MiP service provisions such as UPT and G6PD tests were being passed on to clients, since they could not be charged to the NHIS and the state. Some of the clients who had to pay for such services perceived it as expensive, which discouraged them from accessing maternal health services.
Consequently some missed the opportunity of receiving LLINs early and early uptake of IPTp-SP. Similarly, Klein, Harvey (55) and Hurley, Harvey (56) found that facilities charged lump sums for ANC services, which contributed to women's limited access to IPTp-SP services in Mali.
Managers' exercise of power by instituting fees for maternal health and MiP services, in order to address stock outs and delayed reimbursement, compromised the fee free maternal health service and the MiP policy. Nevertheless, the initiative ensured that facilities functioned and offered uninterrupted services. Women who obtained support from family members and friends and those who earned an income were able to afford the cost of comprehensive ANC service and were appreciative of effective maternal health service delivery. Some of them started ANC early and stuck to their scheduled visits, which enabled them to obtain ITNs early, to start taking SP early and were thus able to complete at least ve doses of SP.
Similarly, studies on exemptions policies for under ve year olds and maternal health services in Ghana and elsewhere found that health care managers dealt with irregular funding and delays in reimbursement from government, which resulted in facilities incurring debt, by modifying exemption policies to selective fee payment (32,37,57,58).
Some women who were unemployed or earned low incomes failed to attend ANC, others delayed initiating ANC attendance, while others skipped scheduled ANC visits, due to their inability to pay for ANC services. Consequently, they did not receive LLINs early, started taking SP late and some did not receive prompt testing and treatment of MiP. Similarly, studies have reported on low uptake of IPTp-SP and access to LLINs among unemployed women and those who could not afford to pay for MiP and other ANC services (30,59) Some ANC clients coped with perceived high cost of MiP and maternal health services by combining visits to health facilities with self-medication, herbal medicines and visiting prayer camps. Similarly, studies in other parts of sub Saharan Africa report that high cost of MiP interventions and maternal health care services demotivated women from accessing them (5,(60)(61)(62). Hill,Kayentao (60), also reported that due to the high cost of maternal health care, women sought alternative care through selfmedication and using herbal medicines.
Some ANC attendees could not pay the full cost of the maternal health care package, so they skipped some aspects. Consequently, health providers could not make informed clinical decisions in order to offer them appropriate treatment. This was a source of frustration and demotivation to health care providers, because they could not exercise power positively, since they could not fully utilize their skills and experiences in the provision of quality maternal health care. Health workers losing motivation as a result of lack of health resources to provide optimum care to clients has been reported (63)(64)(65)(66)(67).
Facilities that did not charge for SP and other medical products, were sometimes cash strapped and could not provide adequate resources for health workers, to enable them provide quality health care to clients. Health providers channeled blame to their managers and district health administration and lost trust in their managers and the health care system, which they perceived as not being responsive to their work news. Gilson (50), has reported on the crucial role of trust in health care institutions, especially between managers and health workers, in ensuring effective health care delivery. Clients equally lost trust in health care providers, as their expectation of accessing comprehensive maternal health care was not met. This affected adherence to treatment, as some women did not purchase the prescribed drugs, so the medical conditions recurred and they believed that health care was not effective. Thus some of the negative outcomes of MiP such as illness, miscarriages and anemia were given spiritual explanation, which encouraged clients to seek alternative sources of health care. The role of trust in provider-client relations and client adherence to treatment have been noted (36,46,68,69). Instituted charges also contributed to clients distrusting health providers, as some believed that health providers bene tted. This probably contributed to the reluctance to pay for maternal health services. Tibandebage and Mackintosh (70) and (Topp and Chipukuma (71)), reported that illegal charges contributed to clients developing distrust of health care providers.

Conclusion And Implication
Managers exercised power by taking initiatives to address MiP policy implementation and arrangement challenges such as stock outs of programme drugs and medical supplies, delayed reimbursement from the NHIS and failure of the MOH to provide medical consumables. The consequences were mixed. Some clients could not access comprehensive MiP care, which affected their trust in the health care system.
Those who could afford services appreciated the uninterrupted ow of services. Health workers sometimes felt frustrated that their clients could not afford comprehensive care, which affected their motivation and trust in their managers.
Policy arrangements in the provision of MiP and Maternal health resources to facilities appears to be changing over time and managers seem to be initiating strategies to cope with this changing trend. The main strategy is passing on some of the cost of the previously free service components of MiP and maternal health service to clients. Consequently, to be able to nd a lasting solution to the MiP and Maternal health policy intervention arrangement challenges, there is the need for a broader policy response to facilities' needs.
The last mile initiative is commendable, but it is not enough, because the initiative only provides drugs to the facilities. So facilities still need to nd money to buy consumables, reagents, to pay casual labour etcetera. This puts a stress on health managers who have to combine managing and supervising staff with the additional burden of nding money to run their facilities. Another important consequence is the increasing burden of the cost of MiP and Maternal health care on clients and the uncertainty of what is free and what should be paid for. This affects the trust relationship between the health system and communities.
Government needs to ensure prompt reimbursement from the NHIS and supply of programme drugs and medical supplies to both government and faith-based facilities, as this is crucial to effective implementation of the MiP intervention. Such a measure will boost facilities' ability to effectively manage and deal with MiP and other maternal health intervention demands, towards the achievement of the reset Abuja targets for IPTp-SP and LLINs in Ghana.
Also, effective and regular communication between the health facilities and the various agencies responsible for providing essential resources for health care is crucial. Effective communication will give the facilities the forum to communicate implementation and arrangement challenges, so that more lasting solutions could be explored.

Consent for publication
The manuscript does not contain any individual's data.

Availability of data and material
The datasets used and/or analyzed during the current study are available from the corresponding author's institution on reasonable request.

Competing interests
The authors declare no competing interest.

Disclaimer
The views expressed in this publication are those of the author(s) and not necessarily those of AAS, NEPAD Agency, Wellcome Trust or the UK government.

Authors' contributions
The study was conceptualized by MD, PM, GA and HT. HT and MG guided the data collection process. MD collected and analysed the data and drafted the manuscript. PM, GA, MG and HT critically revised and commented on the manuscript.

Acknowledgements
We thank the nine research assistants, the Ashanti and Volta Regional Health directorates, the participating district health directorates, health facilities and staff for their support and cooperation. We are grateful to the community leaders and members for the cooperation and support in the conduct of this study.  (72). ii An urban and a rural district were selected in each region in order to re ect the diverse cultural experiences. The initial plan was to select a rural and an urban district in each region, however upon our visit to the Ashanti region, we realized that one of the districts had recently been divided into two, so we went ahead to work in the two districts. iii Conversation is de ned as: 'An informal conversational interview is an unplanned and unanticipated interaction between an interviewer and a respondent that occurs naturally during the course of eldwork observation. in an emergency setting. BMC Medical Ethics, 18, 1-13. In this study women who were visiting ANC were approached for conversations and indepth interviews. Those who had ample time for an interview were given time to re ect and to consent. They were followed to their homes at a later date for interviews. However those who did not have time for interviews were offered the option of conversations and oral consent was conducted on such occasions.