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.85,86 | Volunteers 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.