Figures & Tables
Figures
- FIGURE
National Coverage of CHPS Compounds and NHIS Active Enrollment, Ghana, 1998–2021a
Abbreviations: CHPS, Community-based Health Planning and Services; NHIS, National Health Insurance Scheme.
aCHPS coverage information taken from routine National Health Information System data (red dots represent actual numbers of CHPS compounds reported annually through the National Health Information System and the trend line projects the anticipated achievement of full coverage) and NHIS enrollment estimates (blue bars) are derived from nationally representative population surveys.3–7
The costly construction of permanent facilities where resident nurses can live and provide care is critical to launching community-based primary health care services. Participatory appraisal of this problem generated evidence that communities would contribute volunteer labor, material, and traditional methods for interim facility construction that would be replaced with permanent structures when financing became available. Initially demonstrated in Navrongo, and replicated in Nkwanta, community construction was adopted as a routine Community-based Health Planning and Services (CHPS) component when GEHIP demonstrated procedures for routinizing the method as a means of accelerating the launching of lifesaving CHPS. © 1996 James Phillips/Population Council
Results from the Navrongo experiment showed that volunteer deployment had no impact as a stand-alone scheme. While nurse deployment had major child survival effects, family planning and fertility results depended upon community health nurses and volunteers talking to men in the community about family planning. The joint nurse and volunteer combined staffing model was adopted as national policy. ©1996 James Phillips/Population Council
Tables
- TABLE 1.
Pragmatic Observations Associated With the Navrongo Phase 1 Pilot to Increase Access to Primary Health Care Services, Ghana
Program Component Observation of Pilot Investigators National Policy Outcome Community engagement Traditional and secular leaders support community-based primary health care.74,75 Implementation milestones were documented that included mapping and “community entry.” Gatherings (durbars) contribute to community support.75 Durbars are recognized as effective means of consensus building for community action. Gender problems prevented access to care and women’s inability to realize their reproductive preferences.76 Gender development strategies are essential to the implementation of services that depend upon women’s individual agency. Financing Service financing: “Trust as insurance:” Payment of “cash-and-carry” fees deferred for episodes of care, based on nurse trust that extended families would eventually reimburse the program. None. Start-up costs: The start-up cost of adding community services to the existing program was less than $10 per capita. Communities will construct interim health post facilities at minimal cost, expediting implementation.75 Start-up costs not budgeted until 2009.
Delayed response: Table 3.Nurse training, deployment, and management Existing nurse training programs were urban based; CHN tended to be unfamiliar with rural residence and norms. Localized recruitment and training tested and shown to be more effective than centralized training Training omitted modules on community engagement. A 6-month internship and training module added. CHNs completing this certification redesignated as CHOs. Ghana has 82 languages: CHN were not always deployed in areas where they spoke local languages. District-level recruitment, training, and deployment. Nurses were ineffective family planning service providers if posted to their ancestral community because residents were concerned about possible breaches in confidentiality if providers were members of informal social networks.75,76 Deployment to localities based on language ability; deployment to home communities was avoided. Essential equipment procurement and operation Motorcycles were affordable, but district maintenance capabilities were lacking.
Nurses were relocated from clinic residencies where their families were also based.Logistics development was organized.
Nurses were trained in motorcycle use and basic maintenance.
Fuel delivered to nurses during supervisory outreach rounds.Essential drugs: Nurse deployment accelerated the volume of primary care encounters, depleting pharmaceutical supplies. Logistics reform factored in acceleration of supply requirements. Volunteer recruitment, deployment, and management Volunteer recruitment and deployment is feasible. Volunteers were effective in providing outreach to men. Volunteers recruited in conjunction with CHO deployment; CHO consigned supervisory and community engagement functions. Supervision and management: Community-based care amplified the need for supervisory outreach. District CHPS coordinators added to the CHPS staffing structure with CHO, CHVs, and CHMCs. Abbreviations: CHMC, community health management committee; CHN, community health nurse; CHO, community health officer; CHPS, Community-based Health Planning and Services; CHV, community health volunteers.
- TABLE 2.
Pragmatic Observations and Policy Outcomes Associated With the Navrongo Experiment to Increase Access to Primary Health Care Services, Ghana
Program Component Observation of Pilot Investigators National Policy Outcomes Nurse training, deployment, and management Nurse services have a pronounced impact on child health and survival in experimental cells where community-based nursing was functioning. The combined configuration of worker deployment was adopted as national policy.9 Nurse deployment, without volunteer support, had no impact on family planning use or fertility.31,76 Combining nurse deployment with volunteer-supported community engagement resulted in significant effects on child survival, family planning use, and fertility.32,77 Volunteer recruitment, deployment, and management Volunteer deployment had no impact on child health or survival and no independent effect on family planning or fertility.32,78 Volunteer deployment was a dual cadre initiative whereby volunteers were deployed to support the services of nurses but were not primary service providers. - TABLE 3.
Pragmatic Observations and Policy Outcomes Associated With the Nkwanta Replication Process, Ghana
Program Component Observation of Pilot Investigators National Policy Outcomes Staffing Nurse and volunteer deployment and management Replication of the Navrongo model was feasible and affordable, although cultural heterogeneity required greater focus on community engagement and community-based decentralization than in Navrongo. A 1999 National Health Forum adopted CHPS as national policy.9 The combined configuration of worker deployment was replicated. Implementation results legitimized national implementation policy commitment.79,80 Capacity building Training Within district, implementation required implementation-based team demonstration to supplement technical training.80 Results led to established systems of CHPS-specific operational guidelines and orientation for CHNs before and during deployment. Within-district scale-up Peer learning was essential to community-based replication of CHPS operations. Team exchanges developed systems thinking at each level of the operation.80 Intra-district teams peer exchanges and CHPS operations orientation among facilities was instituted. Between district dissemination of operational learning Although six essential milestones were critical to disseminating CHPS,79,81,82 their replication required participatory learning. Didactic training and documentation of approaches were helpful but insufficient. 82
Eight lead districts were trained in peer learning processes.83District teams’ peer exchanges and CHPS operations’ orientation among districts with CHPS centers of excellence was instituted in other districts (e.g., Birim North, Abura-Asebu-Kwanakese, and Juabeso Bia districts). Support systems learning Supervision and management Supervision was focused on visiting their assigned communities for collaborative problem solving.84 Regular subdistrict health teams and DHMT quarterly supportive supervision were established. Logistics and supply Through the support of another project, the Ghana Essential Medicines Initiative, critical supplies and medicines were made available at CHPS locations that meet the needs of the disease’s profiles of the zones. Basic essential supplies and equipment list was developed for CHPS operations and donor support for logistics was marshaled. Research and knowledge management Within district learning processes Durbars that involved participatory leadership exchanges could be used to spread community-level understanding of CHPS and commitment to scale up. Developed manuals and guidelines for community engagement and understanding of CHPS and community durbars regularized. Scaling up learning Experiential learning through participation and observation was an effective means of building senior official knowledge of implementation processes and results. Annual national health fora and senior managers conferences became focal points for CHPS operations and discussion and performance evaluation. Abbreviations: CHN, community health nurse; CHPS, Community-based Health Planning and Services; CHV, community health volunteers; DHMT, district health management team.
- TABLE 4.
Pragmatic Observations and Policy Outcomes Associated With Monitoring the Scaling Up Process
Functional Component Observation of Investigators Regarding Operational Challenges That Emerged With Time (2000–2008) Interventions and Findings From GEHIP That Were Replicated by the CHPS+ Initiative Staffing Nurse and volunteer deployment and management Volunteer deployment drifted from its original community engagement and male outreach component.
Nurse deployment became increasingly focused on facility-based service delivery with less staff effort directed to field activities and community outreach.85,86Volunteers could be focused on supporting “integrated management of childhood illness” services of CHO, home visit, and male outreach.
Supervisory outreach, outreach scheduling, and management capacity could be developed through demonstration and peer learning.Nurse deployment was delayed by the absence of revenue, plans, or budgetary provision for startup costs. In particular, the construction of community health posts was delayed. Without facilities for residential nurses posting, community-based services cannot commence. Community leaders were committed to solving this problem by mobilizing volunteer construction of health posts.
Grassroots politicians gained an understanding of the popular support for launching CHPS, using development revenue as a seed fund for starting construction.Capacity building Training Team engagement for peer learning that was the hallmark of Nkwanta dissemination success was abandoned, mainly because donor support for exchanges ended and budgets for this activity were absent.
Inservice training focused on technical issues rather than evidence based on quality assurance research.Re-introducing and institutionalizing peer exchanges and sharing practical lessons learned on CHPS operations among intra- and inter-district, as well as inter-regional teams could lead to success in CHPS implementation.Use of implementation research to guide and inform CHPS operations could lead to evidence-based decisions and quality of CHPS services. Within-district scale-up District leader tended to link scale-up to the provision of funds for construction. Community engagement and community volunteer interim construction waned with time.35 Effective community and stakeholder engagement could lead to provision of CHPS infrastructure.
Traditional methods of community mobilization for health actions engender community support for CHPS and availability of interim community-led construction of CHPS facilities.Between-district dissemination of operational learning Opportunities for district leadership to learn about practical strategies for within-district CHPS scale-up because implementation learning was impaired by over-reliance on documentation, didactic training, and meetings.35 Experiential field demonstration was lacking. Each region should have a “systems learning district,” where practical implementation planning and action can be demonstrated. CHPS+ SLD established district demonstration capabilities that merit national replication. If linked to national fora and performance reviews on CHPS, SLD could amplify understanding of CHPS implementation for district teams and leadership. Support systems learning Supervision and management Supervision was found to be effective if linked to outreach activities and engagement with workers in CHPS zones.87 But supervisors were also functioning as sub-district paramedics who relied upon NHIS reimbursement fees. This pattern of costing and compensation contradicted the need for field work and rewarded instead time spent in clinic locations.88 Field and on-the-job coaching and mentorship of CHPS nurses could be more effective in motivating and scaling up CHPS.
The importance of good supportive supervision leads to better capacity of CHPS nurses.Abbreviations: CHN, community health nurse; CHO, community health officer; CHPS, Community-based Health Planning and Services; CHPS+, Program for Strengthening the Implementation of the Community-based Health Planning and Services Initiative in Ghana; GEHIP, Ghana Essential Health Interventions Program; NHIS, National Health Insurance Scheme; SLD, system learning districts.
