Catalyzing the scale-up of community-based primary healthcare in a rural impoverished region of northern Ghana

Community-based Health Planning and Services programme in Ghana: a systematic review

Introduction

Ghana established Community-based Health Planning and Services (CHPS) as the primary point of contact for primary healthcare in 1999. CHPS has since emerged as the country's primary strategy for providing close-to-client healthcare delivery, with numerous positive health outcomes recorded as a result of its implementation. There is, however currently a paucity of systematic reviews of the literature on CHPS. The purpose of this study was not only to investigate dominant trends and research themes in Community-based Health Planning and Services, but also to track the evolution of the CHPS intervention from its inception to the present.

Method

We adopted a systematic review approach for selected articles that were searched on Google Scholar, PubMed, and Scopus databases. The study was conducted and guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. We then applied a reflexive thematic analysis approach in synthesizing the results.

Results

The search resulted in 127 articles of which 59 were included in the final review. Twenty (20) papers targeted the national level, eighteen (18) for the regional level, sixteen (16) for the district level, two (2) for the sub-district level, and three (3) papers targeted the community. The years 2017 and 2019 were recorded to be the years with the highest number of publications on CHPS in Ghana.

Conclusion

Community-based Health Planning and Services (CHPS) is an effective tool in addressing barriers and challenges to accessing quality and affordable health care causing significant effects on health. It provides close-to-client healthcare delivery in the community.

Financing and provision of healthcare for two billion people in low-income nations: Is the cooperative healthcare model a solution?

The international consensus in support of universal health coverage (UHC), though commendable, thus far lacks a clear mechanism to finance and deliver accessible and effective basic healthcare to the two billion rural residents and informal workers of low- and lower-middle-income countries (LLMICs). Importantly, the two preferred financing modes for UHC, general tax revenue and social health insurance, are often infeasible for LLMICs. We identify from historical examples a community-based model that we argue shows promise as a solution to this problem. This model, which we call Cooperative Healthcare (CH), is characterized by community-based risk-pooling and governance and prioritizes primary care. CH leverages communities' existing social capital, such that even those for whom the private benefit of enrolling in a CH scheme is outweighed by the cost may choose to enroll (given sufficient social capital). For CH to be scalable, it needs to demonstrate that it can organize delivery of accessible and reasonable-quality primary healthcare that people value, with management accountable to the communities themselves through structures that people trust, combined with government legitimacy. Once LLMICs with CH programs have industrialized sufficiently to make universal social health insurance feasible, CH schemes can be rolled into such universal programs. We defend cooperative healthcare's suitability for this bridging role and urge LLMIC governments to launch experiments testing it out, with careful adaptation to local conditions.

Implementation of the Community-based Health Planning and Services (CHPS) in rural and urban Ghana: a history and systematic review of what works, for whom and why

Background

Despite renewed emphasis on strengthening primary health care globally, the sector remains under-resourced across sub-Saharan Africa. Community-based Health Planning and Services (CHPS) has been the foundation of Ghana's primary care system for over two decades using a combination of community-based health nurses, volunteers and community engagement to deliver universal access to basic curative care, health promotion and prevention. This review aimed to understand the impacts and implementation lessons of the CHPS programme.

Methods

We conducted a mixed-methods review in line with PRISMA guidance using a results-based convergent design where quantitative and qualitative findings are synthesized separately, then brought together in a final synthesis. Embase, Medline, PsycINFO, Scopus, and Web of Science were searched using pre-defined search terms. We included all primary studies of any design and used the RE-AIM framework to organize and present the findings to understand the different impacts and implementation lessons of the CHPS programme.

Results

N = 58 out of n = 117 full text studies retrieved met the inclusion criteria, of which n = 28 were quantitative, n = 27 were qualitative studies and n = 3 were mixed methods. The geographical spread of studies highlighted uneven distribution, with the majority conducted in the Upper East Region. The CHPS programme is built on a significant body of evidence and has been found effective in reducing under-5 mortality, particularly for the poorest and least educated, increasing use and acceptance of family planning and reduction in fertility. The presence of a CHPS zone in addition to a health facility resulted in increased odds of skilled birth attendant care by 56%. Factors influencing effective implementation included trust, community engagement and motivation of community nurses through salaries, career progression, training and respect. Particular challenges to implementation were found in remote rural and urban contexts.

Conclusions

The clear specification of CHPS combined with a conducive national policy environment has aided scale-up. Strengthened health financing strategies, review of service provision to prepare and respond to pandemics, prevalence of non-communicable diseases and adaptation to changing community contexts, particularly urbanization, are required for successful delivery and future scale-up of CHPS.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=214006, identifier: CRD42020214006.

Community perspectives on cardiovascular disease control in rural Ghana: A qualitative study

BACKGROUND

Cardiovascular disease (CVD) prevalence is high in Ghana-but awareness, prevention, and treatment is sparse, particularly in rural regions. The nurse-led Community-based Health Planning and Services program offers general preventive and primary care in these areas, but overlooks CVD and its risk factors.

METHODS

We conducted in-depth interviews with 30 community members (CM) in rural Navrongo, Ghana to understand their knowledge and beliefs regarding the causes and treatment of CVD and the potential role of community nurses in rendering CVD care. We transcribed audio records, coded these data for content, and qualitatively analyzed these codes for key themes.

RESULTS

CMs described CVD as an acute, aggressive disease rather than a chronic asymptomatic condition, believing that CVD patients often die suddenly. Yet CMs identified causal risk factors for CVD: not only tobacco smoking and poor diet, but also emotional burdens and stressors, which cause and exacerbate CVD symptoms. Many CMs expressed interest in counseling on these risk factors, particularly diet. However, they felt that nurses could provide comprehensive CVD care only if key barriers (such as medication access and training) are addressed. In the interim, many saw nurses' main CVD care role as referring to the hospital.

CONCLUSIONS

CMs would like CVD behavioral education from community nurses at local clinics, but feel the local health system is now too fragile to offer other CVD interventions. CMs believe that a more comprehensive CVD care model would require accessible medication, along with training for nurses to screen for hypertension and other cardiovascular risk factors-in addition to counseling on CVD prevention. Such counseling should build upon existing community beliefs and concerns regarding CVD-including its behavioral and mental health causes-in addition to usual measures to prevent CVD mortality such as diet changes and physical exercise.

Learning Health Systems to Bridge the Evidence-Policy-Practice Gap in Primary Health Care: Lessons From the African Health Initiative

The compilation of lessons in this supplement on the Doris Duke Charitable Foundation’s African Health Initiative’s work in the application of implementation research in primary health care in sub-Saharan Africa reflects the evolution of the discipline that is now increasingly recognized as integral to health systems strengthening.

The Medical Nemesis of Primary Health Care Implementation: Evidence From Ghana

Primary Health Care (PHC), based on the Alma Ata declaration, calls for the movement of responsibility, resources, and control away from medical systems and curative measures toward health promotion. However, PHC implementation in practice appears to be heavily influenced by medical systems with its own attendant effects on the attainment of PHC goals. This study therefore examines the extent and effects of medical systems influence on PHC implementation in Ghana. The study uses the thematic framework approach to qualitative data analysis to analyze data collected from PHC managers through interviews. Ethical clearance for the study was obtained from the Noguchi Memorial Institute for Medical Research. Findings suggest that PHC in practice is tied to the apron-strings of medical systems. While this has catalyzed successes in disease control programs and other medicine-based interventions, it has swayed PHC from its intended shift toward health promotion. Community ownership, participation, and empowerment in PHC is therefore lost in the maze of medical systems which reserves power over PHC decision making and implementation to medical professionals while focusing attention on treatment and curative services. Ultimately, PHC has gradually metamorphosed into mini-clinics instead of the revolutionary community-driven promotive services espoused by Alma Ata with concomitant effects on the attainment of Universal Health Coverage. Further, findings show how gradually, the primary in PHC is being used as a descriptor of the first or basic level of hospital-based care instead of a first point of addressing existing health problems using preventive, promotive, and other community driven approaches. Without a reorientation of health systems, significant efforts and resources are channeled toward empowering health workers instead of local communities with significant effects on the long term sustainability of health efforts and the attainment of UHC. The study recommends further studies toward practical means of reducing the influence of medical systems.

Developing organizational learning for scaling-up community-based primary health care in Ghana

INTRODUCTION

Achieving effective community-based primary health care requires evidence for guiding strategic decisions that must be made. However, research processes often limit data collection to particular organizational levels or disseminate results to specific audiences. Decision-making that emerges can fail to account for the contrasting perspectives and needs of managers at each organizational level. The Ghana Health Service (GHS) addressed this problem with a multilevel and sequential research and action approach that has provided two decades of implementation learning for guiding community-based primary health care development.

METHOD

The GHS implementation research initiatives progressed from (i) a participatory pilot investigation to (ii) an experimental trial of strategies that emerged to (iii) replication research for testing scale-up, culminating in (iv) evidence-based scale-up of a national community-based primary health care program. A reform process subsequently repeated this sequence in a manner that involved stakeholders at the community, sub-district, district, and regional levels of the system. The conduct, interpretation, and dissemination of results that emerged comprised a strategy for achieving systems learning by conducting investigations in phases in conjunction with bottom-up knowledge capture, lateral exchanges for fostering peer learning at each system level, and top-down processes for communicating results as policy. Continuous accumulation of qualitative data on stakeholder reactions to operations at each organizational level was conducted in conjunction with quantitative monitoring of field operations.

RESULTS

Implementation policies were enhanced by results associated with each phase. A quasi-experiment for testing the reform process showed that scale-up of community-based primary health care was accelerated, leading to improvements in childhood survival and reduced fertility.

CONCLUSION

Challenges to system learning were overcome despite severe resource constraints. The integration of knowledge generation with ongoing management processes institutionalized learning for achieving evidence-driven program action.

Institutional mortality rate and cause of death at health facilities in Ghana between 2014 and 2018

BACKGROUND

The epidemiological transition, touted as occurring in Ghana, requires research that tracks the changing patterns of diseases in order to capture the trend and improve healthcare delivery. This study examines national trends in mortality rate and cause of death at health facilities in Ghana between 2014 and 2018.

METHODS

Institutional mortality data and cause of death from 2014-2018 were sourced from the Ghana Health Service's District Health Information Management System. The latter collates healthcare service data routinely from government and non-governmental health institutions in Ghana yearly. The institutional mortality rate was estimated using guidelines from the Ghana Health Service. Percent change in mortality was examined for 2014 and 2018. In addition, cause of death data were available for 2017 and 2018. The World Health Organisation's 11th International Classification for Diseases (ICD-11) was used to group the cause of death.

RESULTS

Institutional mortality decreased by 7% nationally over the study period. However, four out of ten regions (Greater Accra, Volta, Upper East, and Upper West) recorded increases in institutional mortality. The Upper East (17%) and Volta regions (13%) recorded the highest increase. Chronic non-communicable diseases (NCDs) were the leading cause of death in 2017 (25%) and 2018 (20%). This was followed by certain infectious and parasitic diseases (15% for both years) and respiratory infections (10% in 2017 and 13% in 2018). Among the NCDs, hypertension was the leading cause of death with 2,243 and 2,472 cases in 2017 and 2018. Other (non-ischemic) heart diseases and diabetes were the second and third leading NCDs. Septicaemia, tuberculosis and pneumonia were the predominant infectious diseases. Regional variations existed in the cause of death. NCDs showed more urban-region bias while infectious diseases presented more rural-region bias.

CONCLUSIONS

This study examined national trends in mortality rate and cause of death at health facilities in Ghana. Ghana recorded a decrease in institutional mortality throughout the study. NCDs and infections were the leading causes of death, giving a double-burden of diseases. There is a need to enhance efforts towards healthcare and health promotion programmes for NCDs and infectious diseases at facility and community levels as outlined in the 2020 National Health Policy of Ghana.

Positioning the National Health Insurance for financial sustainability and Universal Health Coverage in Ghana: A qualitative study among key stakeholders

INTRODUCTION

The National Health Insurance Scheme (NHIS) was introduced in 2003 to reduce "out-of-pocket" payments for health care in Ghana. Over a decade of its implementation, issues about the financial sustainability of this pro-poor policy remains a crippling fact despite its critical role to go towards Universal Health Coverage. We therefore conducted this study to elicit stakeholders' views on ways to improve the financial sustainability of the operations of NHIS.

METHODS

Twenty (20) stakeholders were identified from Ministry of Health, Ghana Health Services, health workers groups, private medical practitioners, civil society organizations and developmental partners. They were interviewed using an interview guide developed from a NHIS policy review and analysis. All interviews were recorded and transcribed verbatim. The data were analysed thematically with the aid of NVivo 12 software.

RESULTS

Stakeholders admitted that the NHIS is currently unable to meet its financial obligations. The stakeholders suggested first the adoption of capitation as a provider payment mechanism to minimize the risk of providers' fraud and protection from political interference. Secondly, they indicated that rapid releases of specific statutory deductions and taxes for NHIS providers could reduce delays in claims' reimbursement which is one of the main challenges faced by healthcare providers. Aligning the NHIS with the Community-based Health Planning and Services and including preventive and promotive health is necessary to position the Scheme for Universal Health Coverage.

CONCLUSION

The Scheme will potentially achieve UHC if protected from political interference to improve the governance and transparency that affects the finances of the scheme and the expansion of services to include preventive and promotive services and cancers.

Bugs in the Bed: Addressing the Contradictions of Embedded Science with Agile Implementation Research

Implementation research often fails to have its intended impact on what programs actually do. Embedding research within target organizational systems represents an effective response to this problem. However, contradictions associated with the approach often prevent its application. We present case studies of the application of embedded implementation research in Bangladesh, Ghana, and Tanzania where initiatives to strengthen community-based health systems were conducted using the embedded science model. In 2 of the cases, implementation research standards that are typically embraced without question were abandoned to ensure pursuit of embedded science. In the third example, statistical rigor was sustained, but this feature of the design was inconsistent with embedded science. In general, rigorous statistical designs employ units of observation that are inconsistent with organizational units that managers can control. Structural contradictions impede host institution ownership of research processes and utilization of results. Moreover, principles of scientific protocol leadership are inconsistent with managerial leadership. These and other embedded implementation science attributes are reviewed together with contradictions that challenged their pursuit in each case. Based on strategies that were effectively applied to offsetting challenges, a process of merging research with management is proposed that is derived from computer science. Known as "agile science," this paradigm combines scientific rigor with management decision making. This agile embedded research approach is designed to sustain scientific rigor while optimizing the integration of learning into managerial decision making.

Stakeholders perspective of, and experience with contact tracing for COVID-19 in Ghana: A qualitative study among contact tracers, supervisors, and contacts

BACKGROUND

Ghana confirmed the first two cases of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS CoV-2) infection on 12th March 2020. Following this, the government introduced routine and enhanced contact tracing to identify, quarantine, and test contacts for COVID-19. This study, therefore, intends to document the experiences of contact tracers, their supervisors, during COVID-19 containment in Ghana.

METHODS

Purposive sampling was used to select twenty-seven (27) participants; sixteen contact tracers, six supervisors, and five contacts of COVID-19 cases for an in-depth interview using a topic guide. These interviews were conducted on a phone or face-to-face basis whilst maintaining physical distancing protocol. All these were recorded and transcribed verbatim. Then, QSR NVivo 12 was used to analyse the data thematically.

RESULTS

Contact tracers were selected based on their professional background and surveillance experience with other infectious diseases. They were trained before the first confirmed cases of COVID-19 in the country and before deployment. Deployment of contact tracers was in pairs to monitor contacts daily through physical visits or over the phone. Their activities included educating contacts about the condition, filling the symptoms diary, and providing psychological support. Contacts for COVID-19 were identified through case investigation, and their monitoring is done once a day despite the twice-daily requirement. Wherever a case was confirmed, enhanced contact tracing within a 2km radius was done. Furthermore, it was reported that some contacts were not adhering to the self-quarantine. In addition to this, other challenges included; unstable provision of PPEs and remuneration, refusal of some contact to test, delays in receiving test results, and poor coordination of the whole process.

CONCLUSIONS

The study concludes that contact tracing was generally perceived to be helpful in COVID-19 containment in Ghana. However, adhering to self-quarantine protocol had many challenges for both contact tracers and the contacts. Improving coordination and quick release of test results to contacts is necessary for COVID-19 containment. Lastly, the supply of Personal Protection Equipment and motivation needs to be addressed to help position the country well for effective contact tracing.

Volunteer responsibilities, motivations and challenges in implementation of the community-based health planning and services (CHPS) initiative in Ghana: qualitative evidence from two systems learning districts of the CHPS+ project

BACKGROUND

Community volunteerism is essential in the implementation of the Community-based Health Planning and Services (CHPS) in Ghana. We explored the responsibilities, motivations and challenges of community health management committees (CHMCs) in two CHPS+ Project districts in Ghana.

METHODS

We used a qualitative approach to collect data through 4 focus group discussions among a purposive sample of community health volunteers in December 2018 and analysed them thematically.

RESULTS

Community health management committees (CHMCs) were found to provide support in running the CHPS programme through resource mobilisation, monitoring of logistics, assisting the Community Health Officers (CHO) in the planning of CHPS activities, and the resolution of conflicts between CHOs and community members. The value, understanding and protective functions were the key motivations for serving on CHMCs. Financial, logistical and telecommunication challenges, lack of recognition and cooperation from community members, lack of motivation and lack of regular skill development training programmes for CHMC members who serve as traditional birth attendants (TBAs) were major challenges in CHMC volunteerism.

CONCLUSION

Community health volunteerism needs to be prioritised by the Ghana Health Service and other health sector stakeholders to make it attractive for members to give off their best in the discharge of their responsibilities.

Adapting a nurse-led primary care initiative to cardiovascular disease control in Ghana: a qualitative study

Background

Cardiovascular Disease (CVD) is a growing cause of morbidity and mortality in Ghana, where rural primary health care is provided mainly by the Community-based Health Planning and Services (CHPS) initiative. CHPS locates nurses in community-level clinics for basic curative and preventive health services and provides home and outreach services. But CHPS currently lacks capacity to screen for or treat CVD and its risk factors.

Methods

In two rural districts, we conducted in-depth interviews with 21 nurses and 10 nurse supervisors to identify factors constraining or facilitating CVD screening and treatment. Audio recordings were transcribed, coded for content, and analyzed for key themes.

Results

Respondents emphasized three themes: community demand for CVD care; community access to CVD care; and provider capacity to render CVD care. Nurses and supervisors noted that community members were often unaware of CVD, despite high reported prevalence of risk factors. Community members were unable to travel for care or afford treatment once diagnosed. Nurses lacked relevant training and medications for treating conditions such as hypertension. Respondents recognized the importance of CVD care, expressed interest in acquiring further training, and emphasized the need to improve ancillary support for primary care operations.

Conclusions

CHPS staff expressed multiple constraints to CVD care, but also cited actions to address them: CVD-focused training, provision of essential equipment and pharmaceuticals, community education campaigns, and referral and outreach transportation equipment. Results attest to the need for trial of these interventions to assess their impact on CVD risk factors such as hypertension, depression, and alcohol abuse.

Community Involvement and Perceptions of the Community-Based Health Planning and Services (CHPS) Strategy for Improving Health Outcomes in Ghana: Quantitative Comparative Evidence from Two System Learning Districts of the CHPS+ Project

Background. The Community-based Health Planning and Services (CHPS) initiative is Ghana’s flagship strategy for achieving universal health coverage (UHC). Community involvement in and perceptions of CHPS capacity to improve health outcomes of communities are examined. Methods. This community-based descriptive cross-sectional study recruited 1008 adults aged 18 years and above in two System Learning Districts of the CHPS+ project. Data collected were analysed using descriptive and inferential statistics. Results. The level of community involvement in CHPS activities was 48.9% of the population studied. The overall level of positive perception of CHPS services was 51.7%. Community members who were involved in identifying resources (AOR = 1.86 (95% CI = 1.17, 2.97), p=0.009), organising durbars (AOR = 2.09 (95% CI = 1.12, 3.88), p=0.020), and preparing sites for outreach services (AOR = 3.76 (95% CI = 2.23, 6.34), p<0.001) were significantly more likely to have positive perceptions of the relevance of CHPS to improving the health status of communities compared to those who were uninvolved. Conclusion. The level of community involvement in CHPS services is low. Ghana may not be able to attain the UHC goal by 2030 through CHPS implementation unless its level of community involvement is markedly improved. Ghana’s health sector stakeholders should implement community engagement mechanisms that foster improved worker outreach, expanded use of community gatherings, and more active participation of traditional leaders and grassroots political representatives.

A qualitative appraisal of stakeholders' perspectives of a community-based primary health care program in rural Ghana

Background

The Ghana Community-based Health Planning and Services (CHPS) initiative is a national strategy for improving access to primary health care services for underserved communities. Following a successful trial in the North Eastern part of the country, CHPS was adopted as Ghana’s flagship programme for achieving the Universal Health Coverage. Recent empirical evidence suggests, however, that scale-up of CHPS has not necessarily replicated the successes of the pilot study. This study examines the community’s perspective of the performance of CHPS and how the scale up could potentially align with the original experimental study.

Method

Applying a qualitative research methodology, this study analysed transcripts from 20 focus group discussions (FGDs) in four functional CHPS zones in separate districts of the Northern and Volta Regions of Ghana to understand the community’s assessment of CHPS. The study employed the thematic analysis to explore the content of the CHPS service provision, delivery and how community members feel about the service. In addition, ordinary least regression model was applied in interpreting 126 scores consigned to CHPS by the study respondents.

Results

Two broad areas of consensus were observed: general favourable and general unfavourable thematic areas. Favourable themes were informed by approval, appreciation, hard work and recognition of excellent services. The unfavourable thematic area was informed by rudeness, extortion, inappropriate and unprofessional behaviour, lack of basic equipment and disappointments. The findings show that mothers of children under the age of five, adolescent girls without children, and community leaders generally expressed favourable perceptions of CHPS while fathers of children under the age of five and adolescent boys without children had unfavourable expressions about the CHPS program. A narrow focus on maternal and child health explains the demographic divide on the perception of CHPS. The study revealed wide disparities in actual CHPS deliverables and community expectations.

Conclusions

A communication gap between health care providers and community members explains the high and unrealistic expectations of CHPS. Efforts to improve program acceptability and impact should address the need for more general outreach to social networks and men rather than a sole focus on facility-based maternal and child health care.

The fertility impact of achieving universal health coverage in an impoverished rural region of Northern Ghana

Background:  When a successful Navrongo Health Research Centre service experiment demonstrated means for reducing high fertility and childhood mortality in a traditional societal setting of northern Ghana, the Ministry of Health launched a program of national scaling up known as the Community-based Health Planning and Services (CHPS) initiative. For two decades, CHPS has been Ghana’s flagship program for achieving universal health coverage (UHC). When monitoring during its first decade determined that the pace of CHPS scale-up was unacceptably slow, the Ghana Health Service launched the Ghana Essential Health Interventions Program (GEHIP) in four Upper East Region districts to test means of accelerating to CHPS implementation and improving its quality of care.   Methods:  To evaluate GEHIP, a two-round randomized sample survey was fielded with clusters sampled at baseline that were reused in the endline to facilitate difference-in-difference estimation of changes in fertility associated with GEHIP exposure.  Monitoring operations assessed the location, timing, and content of CHPS primary health care. Discrete time hazard regression analysis on merged baseline and endline birth history data permit estimation of GEHIP fertility and CHPS access effects, adjusting for hospital and clinical service access and household social and economic confounders.  Results: GEHIP exposure was associated with an immediate acceleration of CHPS implementation and coverage. Women residing in households with CHPS services had only slightly lower fertility than women who lacked convenient access to CHPS. GEHIP impact on contraceptive use was statistically significant but marginal; GEHIP exposure was associated with increasing unmet need.  Conclusion: Results challenge the assumption that achieving UHC will reduce excess fertility.  Social mobilization, community-outreach, connection of family planning discussions with male social networks are elements of the Navrongo success story that have atrophied with CHPS scale-up.  Achieving UHC does not address the need for renewed attention to these family planning focused strategies.

Out-of-pocket payment for primary healthcare in the era of national health insurance: Evidence from northern Ghana

BACKGROUND

Ghana introduced a national health insurance program in 2005 with the goal of removing user fees, popularly called "cash and carry", along with their associated catastrophic and impoverishment effects on the population and ensuring access to equitable health care. However, after a decade of implementation, the impact of this program on user fees and out-of-pocket payment (OOP) is not properly documented. This paper contributes to understanding the impact of Ghana's health insurance program on out-of-pocket healthcare payments and the factors associated with the level of out-of-pocket payments for primary healthcare in a predominantly rural region of Ghana.

METHODS

Using a five-year panel data of revenues accruing to public primary health facilities in seven districts, We employed mean comparison tests (t-test) to examine the trend in revenues accruing from out-of-pocket payments vis-à-vis health insurance claims for health services, medication, and obstetric care. Furthermore, generalized estimation equation regression models were used to assess the relationship between explanatory variables and the level of out-of-pocket payments and health insurance claims.

RESULTS

Out-of-pocket payment for health services and medications declined by 63% and 62% respectively between 2010 and 2014. Insurance claims however increased by 16% within the same period. There was statistically a significant mean reduction in out-of-pocket payment over the period. Factors significantly associated with out-of-pocket payments in a given district are the number of community health facilities, availability of a district hospital and the year of observation.

CONCLUSION

The study provides evidence that Ghana's national health insurance program is significantly contributing to a reduction in out-of-pocket payment for primary healthcare in public health facilities. Efforts should therefore be put in place to ensure the sustainability of this policy as a major pathway for achieving universal health coverage in Ghana.

Cost of implementing a community-based primary health care strengthening program: The case of the Ghana Essential Health Interventions Program in northern Ghana

Background

The absence of implementation cost data constrains deliberations on consigning resources to community-based health programs. This paper analyses the cost of implementing strategies for accelerating the expansion of a community-based primary health care program in northern Ghana. Known as the Ghana Essential Health Intervention Program (GEHIP), the project was an embedded implementation science program implemented to provide practical guidance for accelerating the expansion of community-based primary health care and introducing improvements in the range of services community workers can provide.

Methods

Cost data were systematically collected from intervention and non-intervention districts throughout the implementation period (2012–2014) from a provider perspective. The step-down allocation approach to costing was used while WHO health system blocks were adopted as cost centers. We computed cost without annualizing capital cost to represent financial cost and cost with annualizing capital cost to represent economic cost.

Results

The per capita financial cost and economic cost of implementing GEHIP over a three-year period was $1.79, and $1.07 respectively. GEHIP comprised only 3.1% of total primary health care cost. Health service delivery comprised the largest component of cost (37.6%), human resources was 28.6%, medicines was 13.6%, leadership/governance was 12.8%, while health information comprised 7.5% of the economic cost of implementing GEHIP.

Conclusion

The per capita cost of implementing the GEHIP program was low. GEHIP project investments had a catalytic effect that improved community-based health planning and services (CHPS) coverage and enhanced the efficient use of routine health system resources rather than expanding overall primary health care costs.

What do you do with success? The science of scaling up a health systems strengthening intervention in Ghana

Background

The completion of an implementation research project typically signals the end of research. In contrast, the Ghana Health Service has embraced a continuous process of evidence-based programming, wherein each research episode is followed by action and a new program of research that monitors and guides the utilization of lessons learned. This paper reviews the objectives and design of the most recent phase in this process, known as a National Program for Strengthening the Implementation of the Community-based Health Planning and Services (CHPS) Initiative in Ghana (CHPS+).

Methods

A mixed method evaluation strategy has been launched involving: i) baseline and endline randomized sample surveys with 247 clusters dispersed in 14 districts of the Northern and Volta Regions to assess the difference in difference effect of stepped wedge differential cluster exposure to CHPS+ activities on childhood survival, ii) a monitoring system to assess the association of changes in service system readiness with CHPS+ interventions, and iii) a program of qualitative systems appraisal to gauge stakeholder perceptions of systems problems, reactions to interventions, and perceptions of change. Integrated survey and monitoring data will permit multi-level longitudinal models of impact; longitudinal QSA data will provide data on the implementation process.

Discussion

A process of exchanges, team interaction, and catalytic financing has accelerated the expansion of community-based primary health care in Ghana’s Upper East Region (UER). Using two Northern and two Volta Region districts, the UER systems learning concept will be transferred to counterpart districts where a program of team-based peer training will be instituted. A mixed method research system will be used to assess the impact of this transfer of innovation in collaboration with national and regional program management. This arrangement will generate embedded science that optimizes prospects that results will contribute to national CHPS reform policies and action.

Health system strengthening: a qualitative evaluation of implementation experience and lessons learned across five African countries

BACKGROUND

Achieving the United Nations Sustainable Development Goals in sub-Saharan Africa will require substantial improvements in the coverage and performance of primary health care delivery systems. Projects supported by the Doris Duke Charitable Foundation's (DDCF) African Health Initiative (AHI) created public-private-academic and community partnerships in five African countries to implement and evaluate district-level health system strengthening interventions. In this study, we captured common implementation experiences and lessons learned to understand core elements of successful health systems interventions.

METHODS

We used qualitative data from key informant interviews and annual progress reports from the five Population Health Implementation and Training (PHIT) partnership projects funded through AHI in Ghana, Mozambique, Rwanda, Tanzania, and Zambia.

RESULTS

Four major overarching lessons were highlighted. First, variety and inclusiveness of concerned key players (public, academic and private) are necessary to address complex health system issues at all levels. Second, a learning culture that promotes evidence creation and ability to efficiently adapt were key in order to meet changing contextual needs. Third, inclusion of strong implementation science tools and strategies allowed informed and measured learning processes and efficient dissemination of best practices. Fourth, five to seven years was the minimum time frame necessary to effectively implement complex health system strengthening interventions and generate the evidence base needed to advocate for sustainable change for the PHIT partnership projects.

CONCLUSION

The AHI experience has raised remaining, if not overlooked, challenges and potential solutions to address complex health systems strengthening intervention designs and implementation issues, while aiming to measurably accomplish sustainable positive change in dynamic, learning, and varied contexts.

Bridging the intervention-implementation gap in primary health care delivery: the critical role of integrated implementation research

For national and local leaders to achieve universal health coverage, a new approach or technique to gathering evidence and understanding the contexts that influence the outcome of a study and goes beyond the quantitative results of clinical trials and pilot projects is important. The Doris Duke Charitable Foundation's African Health Initiative (AHI) was designed to produce this type of knowledge through embedding implementation research into Population Health Implementation and Training (PHIT) partnership projects in five countries (Ghana, Mozambique, Rwanda, Tanzania, and Zambia) with the goal of improving primary health care and population health. In Ghana, this integration of research into implementation has contributed to the successful testing, adaptation and implementation of the Community-based Health Planning and Services (CHPS) model (The Navrongo Pilot Project), with results from the AHI-funded work informing national scale-up of effective practices. Further application of implementation science methods and frameworks to study cross-project lessons also produced the evidence needed by national and local decision makers on how and why different intervention components were successful and where and how local context drove implementation and adaptation. Cross-project research also identified effective approaches across diverse settings for building capacity for data-driven improvement, coaching and mentoring clinicians and researchers, developing locally appropriate interventions to reduce neonatal mortality, and integrating implementation research to inform local implementers and researchers in more effective strategies to strengthen health systems and improve health services and population health. Evidence has already shown the potential for this type of work to accelerate regional learning and spread of successful interventions to achieve targeted health goals more efficiently, better enabling countries to achieve the ambitious, but important, U.N. Sustainable Development Goals.

Mentorship and coaching to support strengthening healthcare systems: lessons learned across the five Population Health Implementation and Training partnership projects in sub-Saharan Africa

Background

Despite global efforts to increase health workforce capacity through training and guidelines, challenges remain in bridging the gap between knowledge and quality clinical practice and addressing health system deficiencies preventing health workers from providing high quality care. In many developing countries, supervision activities focus on data collection, auditing and report completion rather than catalyzing learning and supporting system quality improvement. To address this gap, mentorship and coaching interventions were implemented in projects in five African countries (Ghana, Mozambique, Rwanda, Tanzania, and Zambia) as components of health systems strengthening (HSS) strategies funded through the Doris Duke Charitable Foundation’s African Health Initiative. We report on lessons learned from a cross-country evaluation.

Methods

The evaluation was designed based on a conceptual model derived from the project-specific interventions. Semi-structured interviews were administered to key informants to capture data in six categories: 1) mentorship and coaching goals, 2) selection and training of mentors and coaches, 3) integration with the existing systems, 4) monitoring and evaluation, 5) reported outcomes, and 6) challenges and successes. A review of project-published articles and technical reports from the individual projects supplemented interview information.

Results

Although there was heterogeneity in the approaches to mentorship and coaching and targeted areas of the country projects, all led to improvements in core health system areas, including quality of clinical care, data-driven decision making, leadership and accountability, and staff satisfaction. Adaptation of approaches to reflect local context encouraged their adoption and improved their effectiveness and sustainability.

Conclusion

We found that incorporating mentorship and coaching activities into HSS strategies was associated with improvements in quality of care and health systems, and mentorship and coaching represents an important component of HSS activities designed to improve not just coverage, but even further effective coverage, in achieving Universal Health Care.

Utilization of community-based health planning and services compounds in the Kintampo North Municipality: a cross-sectional descriptive correlational study

BACKGROUND

The Community-based Health Planning and Services (CHPS) initiative was introduced to improve coverage and utilization of basic health services for people in remote rural communities whose use of orthodox health services was hitherto limited by distance. To achieve this aim, the scheme has so far been scaled up to several communities nationwide as part of government's agenda to improve the general wellbeing of the populace. The objectives of this study were to examine the extent of patronage of CHPS compounds in the Kintampo North Municipality, factors associated with their use and challenges faced by community members regarding the use of these facilities.

METHODS

We adopted a descriptive cross-sectional correlational design for this study. We collected data from 171 household heads or their representatives, selected through a multistage sampling technique. The respondents were drawn from five randomly selected communities among those with CHPS compounds and their proportions weighted based on the populations of these communities.

RESULTS

Our analysis revealed that a high proportion (73.7%) of the respondents patronized CHPS compounds for health care. We also found sex and income to predict the use of the facilities though income was less significant after adjusting for sex in a multivariate analysis. Females were about six times more likely than males to patronize CHPS compounds (adjusted OR = 5.98, 95% CI 2.55, 14.0, P = < 0.01). Household heads earning between GH¢ 200.00 and GH¢ 300.00 were about nine times more likely to use the facilities than those who earned below GH¢ 100.00 (adjusted OR = 8.88, 95% CI 1.94, 40.6, P = 0.05). Our findings also showed that shortage of medicines (41.5%), lack of money to pay for services (28.7%) and absenteeism of Community Health Officers (CHOs) (12.3%) were major barriers to the use of the facilities.

CONCLUSIONS

Based on the foregoing findings, there is an apparent need to ensure timely replenishment of medicines at the facilities and step up supervision of CHOs in order to sustain patronage of the compounds.

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 8. summary and recommendations of the Expert Panel

BACKGROUND

The contributions that community-based primary health care (CBPHC) and engaging with communities as valued partners can make to the improvement of maternal, neonatal and child health (MNCH) is not widely appreciated. This unfortunate reality is one of the reasons why so few priority countries failed to achieve the health-related Millennium Development Goals by 2015. This article provides a summary of a series of articles about the effectiveness of CBPHC in improving MNCH and offers recommendations from an Expert Panel for strengthening CBPHC that were formulated in 2008 and have been updated on the basis of more recent evidence.

METHODS

An Expert Panel convened to guide the review of the effectiveness of community-based primary health care (CBPHC). The Expert Panel met in 2008 in New York City with senior UNICEF staff. In 2016, following the completion of the review, the Panel considered the review's findings and made recommendations. The review consisted of an analysis of 661 unique reports, including 583 peer-reviewed journal articles, 12 books/monographs, 4 book chapters, and 72 reports from the gray literature. The analysis consisted of 700 assessments since 39 were analyzed twice (once for an assessment of improvements in neonatal and/or child health and once for an assessment in maternal health).

RESULTS

The Expert Panel recommends that CBPHC should be a priority for strengthening health systems, accelerating progress in achieving universal health coverage, and ending preventable child and maternal deaths. The Panel also recommends that expenditures for CBPHC be monitored against expenditures for primary health care facilities and hospitals and reflect the importance of CBPHC for averting mortality. Governments, government health programs, and NGOs should develop health systems that respect and value communities as full partners and work collaboratively with them in building and strengthening CBPHC programs - through engagement with planning, implementation (including the full use of community-level workers), and evaluation. CBPHC programs need to reach every community and household in order to achieve universal coverage of key evidence-based interventions that can be implemented in the community outside of health facilities and assure that those most in need are reached.

CONCLUSIONS

Stronger CBPHC programs that foster community engagement/empowerment with the implementation of evidence-based interventions will be essential for achieving universal coverage of health services by 2030 (as called for by the Sustainable Development Goals recently adopted by the United Nations), ending preventable child and maternal deaths by 2030 (as called for by the World Health Organization, UNICEF, and many countries around the world), and eventually achieving Health for All as envisioned at the International Conference on Primary Health Care in 1978. Stronger CBPHC programs can also create entry points and synergies for expanding the coverage of family planning services as well as for accelerating progress in the detection and treatment of HIV/AIDS, tuberculosis, malaria, hypertension, and other chronic diseases. Continued strengthening of CBPHC programs based on rigorous ongoing operations research and evaluation will be required, and this evidence will be needed to guide national and international policies and programs.

Social Factors Influencing Child Health in Ghana

Objectives

Social factors have profound effects on health. Children are especially vulnerable to social influences, particularly in their early years. Adverse social exposures in childhood can lead to chronic disorders later in life. Here, we sought to identify and evaluate the impact of social factors on child health in Ghana. As Ghana is unlikely to achieve the Millennium Development Goals’ target of reducing child mortality by two-thirds between 1990 and 2015, we deemed it necessary to identify social determinants that might have contributed to the non-realisation of this goal.

Methods

ScienceDirect, PubMed, MEDLINE via EBSCO and Google Scholar were searched for published articles reporting on the influence of social factors on child health in Ghana. After screening the 98 articles identified, 34 of them that met our inclusion criteria were selected for qualitative review.

Results

Major social factors influencing child health in the country include maternal education, rural-urban disparities (place of residence), family income (wealth/poverty) and high dependency (multiparousity). These factors are associated with child mortality, nutritional status of children, completion of immunisation programmes, health-seeking behaviour and hygiene practices.

Conclusions

Several social factors influence child health outcomes in Ghana. Developing more effective responses to these social determinants would require sustainable efforts from all stakeholders including the Government, healthcare providers and families. We recommend the development of interventions that would support families through direct social support initiatives aimed at alleviating poverty and inequality, and indirect approaches targeted at eliminating the dependence of poor health outcomes on social factors. Importantly, the expansion of quality free education interventions to improve would-be-mother’s health knowledge is emphasised.