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.