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Original Articles
Open Access

Lessons learned from scaling up a community-based health program in the Upper East Region of northern Ghana

John Koku Awoonor-Williams, Elias Kavinah Sory, Frank K Nyonator, James F Phillips, Chen Wang and Margaret L Schmitt
Global Health: Science and Practice March 2013, 1(1):117-133; https://doi.org/10.9745/GHSP-D-12-00012
John Koku Awoonor-Williams
aGhana Health Service, Upper East Regional Health Administration, Bolgatanga, Ghana
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Elias Kavinah Sory
bGhana Health Service, Accra, Ghana
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Frank K Nyonator
bGhana Health Service, Accra, Ghana
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James F Phillips
cColumbia University, Mailman School of Public Health, New York City, New York, USA
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Chen Wang
cColumbia University, Mailman School of Public Health, New York City, New York, USA
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Margaret L Schmitt
cColumbia University, Mailman School of Public Health, New York City, New York, USA
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Figures & Tables

Figures

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  • FIGURE 1.
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    FIGURE 1.

    Phases in the Ghana Program Development Process

    Source: Reference 14.

  • FIGURE 2.
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    FIGURE 2.

    Navrongo Experimental Trial Intervention Groups, Kassena-Nankana District, Ghana

    Source: Reference 32.

  • FIGURE 3.
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    FIGURE 3.

    Geographic Density of CHPS Coverage by District, Ghana, January 2001 and July 2008

    Abbreviations: CHPS, Community-Based Health Planning and Services.

    Source: Reference 15.

  • FIGURE 4.
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    FIGURE 4.

    Percentage of the Population Served by Workers of the CHPS Program, by Region and Nationwide, September 2000 to June 2008

    Abbreviations: CHPS, Community-Based Health Planning and Services.

    Source: Reference 15.

Tables

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    Table 1. CHPS Scaling-Up Constraints and Responses in the Upper East Region (UER) Related to Recruitment, Training, and Deployment of Community Health Officers
    Constraint TypeBarriers to Scaling UpActions Implemented in the UERGlobal Implications
    Limited range of services
    • Deficient range of services. Community health officers (CHOs) were unprepared for essential services (midwifery, emergency management, immediate post-delivery care).

    • Over-extension of job descriptions

    • Piloted and scaled up community-engaged referral system

    • Trained CHOs in strategies for saving newborn lives

    • Focus roles on the burden of disease and family planning

    • Risk transition. Community-based primary health care reduces the burden of disease. Emergency-related causes comprise an increased proportion of the remaining unaddressed burden.

    • Community-based planning. Developing effective referral systems requires adapting operations to community road conditions and communication needs.

    Inappropriate CHO recruitment
    • Insufficient nurse manpower

    • Centralized recruitment results in deployment of workers to localities where they are not conversant with local languages or customs.

    • Expanded nurse training school volume

    • Recruited trainees from districts where they are to be assigned and involved health committees in selection process

    • Bottom-up planning. Community health systems development requires “bottom up” strategic planning so that scale up builds capacity that effectively links services to local cultural conditions, languages, and health needs.

    • Plan for ethnic diversity. Community-engaged recruitment reduces turnover and improves performance, morale, and community ownership.

    Inappropriate CHO training
    • Pre-service training. Existing 18-month training program does not address community engagement, service outreach, and community health care planning. Overreliance on didactic training and shortage of locations and equipment for mentoring arrangements hinder CHO preparedness.

    • In-service training. Relocating nurses from clinics to villages requires training them to be community organizers with liaison and diplomatic skills.

    • Implemented 6-month regional CHO internships focused on community engagement

    • Organized peer mentoring coordinated with the training school curriculum

    • Systems approach to manpower development. Equipment and budgetary planning should integrate the process of pre-service, internship, and in-service training and plan for peer-mentoring arrangements.

    • Community-engaged peer leadership. Didactic health technology training is insufficient.

    Inappropriate CHO deployment
    • Insufficient programmatic focus on household services; health posts are the main service point.

    • The National Health Insurance Scheme (NHIS) incentivized static services at the expense of doorstep care, reducing access.

    • NHIS reimbursement for the provision of clinical services de-emphasizes supervisory outreach.

    • Developed supervisory work routines that are independent of NHIS reimbursement rules

    • Systems approach to CHO deployment, monitoring, and supervision. Programs that focus narrowly on a single community health worker cadre, health problem, or function are risky. “Learning localities” are needed where systems functioning is comprehensively monitored and where lessons learned are communicated to senior officials.

    • Compatibility of reimbursement schemes with doorstep care. National Health Insurance schemes require careful trial of their impact on non-clinic based community-based service operations.

    Inappropriate volunteer deployment
    • Volunteers providing antipyretics can inadvertently delay parental health-seeking behavior, elevating risk. With careful training and supervision, however, volunteers can provide integrated management of childhood illness (IMCI).

    • Training volunteers in social engagement methods is essential.

    • Female health volunteers are more committed to service activities than male volunteers, but male volunteers are critical to family planning promotion.

    • Risk mitigation with field research: Reliance on untested imported initiatives is risky.

    • Partial IMCI does not work: Volunteer services can cause more harm than good unless volunteer deployment is coordinated with deployment of trained nurses and governed by rigorous supervision.

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    Table 2. CHPS Scaling-Up Constraints and Responses in the Upper East Region (UER) Related to Support of District Health Systems
    Constraint TypeBarriers to Scaling UpActions Implemented in the UERGlobal Implications
    Information Systems
    Cumbersome information systems
    • Unwieldy Health Management Information Systems (HMIS) require more staff time for data management than is available for service delivery.

    • Simplified registers from 27 to 5

    • Developed monitoring tools for outreach and supervisory support

    • Inappropriate information systems can impede worker commitment to scaling up.

    Lack of information utilization
    • Lack of feedback or systems for information utilization

    • Developed simple-to-implement data visualization tools

    • Implementation and supervisory support information is neglected in HMIS design.

    Lack of essential information
    • Absence of actionable information about perinatal risks and causes of death

    • Developed maternal and neonatal mortality audit scheme with weekly medical review of results

    • Training and staff development require tools for evidence-based planning.

    Essential Equipment, Supplies, and Facilities
    Shortage of community-based health facilities
    • High cost and slow pace of health post construction

    • Official restrictions on the use of Ghana Health Service revenue for construction

    • Constructed interim facilities through community engagement and by volunteers

    • Leveraged financing of construction through outreach to district political and development-sector leadership

    • Community investment in construction can facilitate engagement in health systems development.

    Lack of essential equipment
    • Shortage of motorbikes and ambulances

    • Lack of electrification, wells, and amenities

    • Obtained support from UNICEF and other donors for essential equipment, solar panels, and batteries

    • Low-cost equipment can be expensive to maintain.

    • Investment in electrification and amenities reduces worker turnover and supports scale up.

    Lack of essential commodities
    • Stockouts of essential drugs

    • Expansion of services without expansion of access to supplies

    • Implemented simple stock monitoring and logistics reporting tool

    • Total systems planning is essential to effective community-based service development.

    Planning and Resources
    Lack of financial planning and budgets
    • Absence of a budget line for CHPS

    • Implemented District Health Planning and Reporting Toolkit (2010)

    • Slow scale up can be addressed by clarifying resource management requirements and the health rationale for community-based services to grassroots politicians and leaders.

    Lack of flexible resources
    • Extreme constraints on resources for the Common Fund

    • Cash flow delays

    • Leveraged financing of the Common Fund (3 districts only)

    • CHPS lacks earmarked support from international donors. Instead, external resources are focused on technical assistance. Requiring a resource-constrained system to invest in incremental resources is unrealistic.

    Leadership and Governance
    Lack of leadership for CHPS
    • Absence of district and regional leadership for CHPS implementation

    • Lack of facilitative supervision

    • Implemented peer leadership exchanges between Navrongo and district teams and between leading district teams and counterparts

    • Implemented supervisory peer leadership exchanges

    • Leadership is developed through transfer of knowledge via onsite demonstration and participatory exchanges. Workshops are an ineffective tool for leadership development.

    Failure to replicate Navrongo community engagement
    • Lack of community entry and engagement

    • Limited focus on establishing community health committees

    • Absence of mechanisms for durbars and community exchanges

    • Employed social engagement strategies, including outreach to chiefs and elders, engagement with social networks and opinion leaders, community durbars for building consensus and collective action

    • Social engagement, gender strategies, and traditional governance strategies can be diluted with scale up. Resources for exchanges, demonstration, and discussion of social organizational issues can be crucial to effective scale up of community health service strategies.

    Absence of political support
    • Absence of political engagement strategies

    • Limited district development investment in health

    • Mobilized resources for health post construction through grassroots political support

    • Siloing community health development in the health sector can detract from scale up. Grassroots political engagement can contribute to offsetting resource limitations.

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Global Health: Science and Practice: 1 (1)
Global Health: Science and Practice
Vol. 1, No. 1
March 01, 2013
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Lessons learned from scaling up a community-based health program in the Upper East Region of northern Ghana
John Koku Awoonor-Williams, Elias Kavinah Sory, Frank K Nyonator, James F Phillips, Chen Wang, Margaret L Schmitt
Global Health: Science and Practice Mar 2013, 1 (1) 117-133; DOI: 10.9745/GHSP-D-12-00012

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Lessons learned from scaling up a community-based health program in the Upper East Region of northern Ghana
John Koku Awoonor-Williams, Elias Kavinah Sory, Frank K Nyonator, James F Phillips, Chen Wang, Margaret L Schmitt
Global Health: Science and Practice Mar 2013, 1 (1) 117-133; DOI: 10.9745/GHSP-D-12-00012
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  • Article
    • ABSTRACT
    • INTRODUCTION
    • WHAT IS CHPS?
    • PHASED PROGRAM DEVELOPMENT OF CHPS
    • CHPS SCALE-UP CHALLENGES AND UPPER EAST REGION SOLUTIONS
    • CONCLUSION
    • Acknowledgments
    • Notes
    • References
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