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Asiedu A, Haws RA, Gyasi A, Boateng P, Malm K, Ntumy R, Oseni L, Tetteh G. Improving Malaria Case Management and Referral Relationships at the Primary Care Level in Ghana: Evaluation of a Quality Assurance Internship. GLOBAL HEALTH, SCIENCE AND PRACTICE 2023; 11:e2300050. [PMID: 38135513 PMCID: PMC10749655 DOI: 10.9745/ghsp-d-23-00050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 10/10/2023] [Indexed: 12/24/2023]
Abstract
In Ghana, Community-based Health Planning and Services (CHPS) compounds managed by trained nurses and midwives called community health officers (CHOs) play a major role in malaria service delivery. With heavy administrative burdens and minimal training in providing patient care, particularly for febrile illnesses, including malaria, CHOs struggle to comply with the World Health Organization's test, treat, and track initiative guidelines and appropriate referral practices. A clinical training and mentorship program was implemented for CHOs to prevent and manage uncomplicated malaria and offer appropriate pre-referral treatment and referrals to district hospitals. Medical officers, pharmacists, midwives, health information officers, and medical laboratory scientists at 52 district referral hospitals were trained as mentors; CHOs from 520 poorly performing CHPS compounds underwent a 5-day internship at their assigned district referral hospital to improve knowledge and clinical skills for malaria case management. Three months later, mentors conducted post-training mentoring visits to assess knowledge and skill retention and provide ongoing on-the-job guidance. Significant percentage-point increases were observed immediately post-internship for history taking (+12.0, 95% confidence interval [CI]=8.3, 15.1; P<.001); fever assessment (+24.9, 95% CI=20.9, 29.3; P<.001); severe malaria assessment and referral (+32.0, 95% CI=28.2, 35.8; P<.001); and knowledge assessment (+15.8, 95% CI=10.0, 21.3; P<.001). Three months later, a third assessment revealed these gains were largely maintained. Analysis of national health management information system data showed statistically significant improvements in testing, treatment, and referral indicators at intervention CHPS compounds after the intervention that were not observed in comparison CHPS compounds. This training and mentorship approach offers a replicable model to build primary care provider competencies in malaria prevention and management and demonstrates how developing relationships between primary care and first-level referral facilities benefits both providers and clients. More methodologically rigorous studies are needed to measure the impact of this approach.
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Affiliation(s)
- Amos Asiedu
- U.S. President's Malaria Initiative, Impact Malaria Project, Accra, Ghana
| | - Rachel A Haws
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Akosua Gyasi
- U.S. President's Malaria Initiative, Impact Malaria Project, Accra, Ghana
| | - Paul Boateng
- National Malaria Control Programme, Accra, Ghana
| | - Keziah Malm
- National Malaria Control Programme, Accra, Ghana
| | - Raphael Ntumy
- U.S. President's Malaria Initiative, Impact Malaria Project, Accra, Ghana
| | - Lolade Oseni
- U.S. President's Malaria Initiative, Impact Malaria Project, Jhpiego, Baltimore, MD, USA
| | - Gladys Tetteh
- U.S. President's Malaria Initiative, Impact Malaria Project, Jhpiego, Baltimore, MD, USA
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Elsey H, Abboah-Offei M, Vidyasagaran AL, Anaseba D, Wallace L, Nwameme A, Gyasi A, Ayim A, Ansah-Ofei A, Amedzro N, Dovlo D, Agongo E, Awoonor-Williams K, Agyepong I. 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. Front Public Health 2023; 11:1105495. [PMID: 37435526 PMCID: PMC10332345 DOI: 10.3389/fpubh.2023.1105495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 05/11/2023] [Indexed: 07/13/2023] Open
Abstract
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.
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Affiliation(s)
- Helen Elsey
- Department of Health Sciences, Hull York Medical School, University of York, York, United Kingdom
| | - Mary Abboah-Offei
- School of Health and Life Sciences, University of the West of Scotland (London Campus), London, United Kingdom
| | | | - Dominic Anaseba
- Faculty of Public Health, Ghana College of Physicians and Surgeons, Accra, Ghana
| | - Lauren Wallace
- Dodowa Health Research Centre, Research and Development Division, Ghana Health Service, Accra, Ghana
| | - Adanna Nwameme
- Department of Social and Behavioural Sciences, School of Public Health, University of Ghana, Accra, Ghana
| | - Akosua Gyasi
- Faculty of Public Health, Ghana College of Physicians and Surgeons, Accra, Ghana
| | - Andrews Ayim
- Faculty of Public Health, Ghana College of Physicians and Surgeons, Accra, Ghana
| | | | - Nina Amedzro
- Department of Health Sciences, Hull York Medical School, University of York, York, United Kingdom
| | - Delanyo Dovlo
- Faculty of Public Health, Ghana College of Physicians and Surgeons, Accra, Ghana
| | - Erasmus Agongo
- Faculty of Public Health, Ghana College of Physicians and Surgeons, Accra, Ghana
| | | | - Irene Agyepong
- Faculty of Public Health, Ghana College of Physicians and Surgeons, Accra, Ghana
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Sakeah E, Bawah AA, Asuming PO, Debpuur C, Welaga P, Awine T, Anyorikeya M, Kuwolamo I, Oh J, Lee HS, Lee HY, Lee I, Kim MS, Hong S, Awoonor-Williams JK, Phillips JF, Aboagye P, Oduro AR. Impact of community health interventions on maternal and child health indicators in the upper east region of Ghana. BMC Pregnancy Childbirth 2023; 23:298. [PMID: 37118693 PMCID: PMC10141815 DOI: 10.1186/s12884-023-05577-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 04/05/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND This paper reports on results of a health system strengthening implementation research initiative conducted the Upper East Region of northern Ghana. Transformative interventions to accelerate and strengthen the health delivery were implemented that included empowering community leaders and members to actively participate in health delivery, strengthening the referral systems through the provision of community transport systems, providing basic medical equipment to community clinics, and improving the skills of critical health staff through training. METHODS A mixed method design was used to evaluate the impact of the interventions. A quantitative evaluation employed a flexible research design to test the effects of various component activities of the project. To assess impact, a pre-versus-post randomized cluster survey design was used. Qualitative research was conducted with focus group data and individual in depth interviews to gauge the views of various stakeholders associated with the implementation process. RESULTS After intervention, significant improvements in key maternal and child health indicators such as antenatal and postnatal care coverage were observed and increases in the proportion of deliveries occurring in health facilities and assisted by skilled health personnel relative to pre-intervention conditions. There was also increased uptake of oral rehydration salts (ORS) for treatment of childhood diarrhoea, as well as marked reductions in the incidence of upper respiratory infections (URI). CONCLUSIONS A pre-and post-evaluation of impact suggests that the programme had a strong positive impact on the functioning of primary health care. Findings are consistent with the proposition that the coverage and content of the Ghana Community-based Health Planning and Services programme was improved by program interventions and induced discernable changes in key indicators of health system performance.
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Affiliation(s)
- Evelyn Sakeah
- Navrongo Health Research Centre, Ghana Health Service, Navrongo, Ghana
- School of Public Health, CK Tedam University of Technology and Applied Sciences, Navrongo, Ghana
| | - Ayaga A Bawah
- Regional Institute for Population Studies, University of Ghana, Legon, Accra, Ghana.
| | - Patrick O Asuming
- Business School, University of Ghana, University of Ghana, Legon, Accra, Ghana
| | | | - Paul Welaga
- Navrongo Health Research Centre, Ghana Health Service, Navrongo, Ghana
- School of Public Health, CK Tedam University of Technology and Applied Sciences, Navrongo, Ghana
| | - Timothy Awine
- Navrongo Health Research Centre, Ghana Health Service, Navrongo, Ghana
| | - Maria Anyorikeya
- Navrongo Health Research Centre, Ghana Health Service, Navrongo, Ghana
| | - Irene Kuwolamo
- Navrongo Health Research Centre, Ghana Health Service, Navrongo, Ghana
| | - Juhwan Oh
- College of Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hoon Sang Lee
- RIGHT (Research Investment for Global Health Technology) Foundation, Seoul, Republic of Korea
| | - Hwa-Young Lee
- Graduate School of Public Health and Healthcare Management, The Catholic University of Korea, Seoul, Republic of Korea
| | - Inseok Lee
- KOICA Ghana Project Implementation Unit, Accra, Ghana
| | | | - Seoyeon Hong
- Seoul National University College of Medicine, Seoul, Republic of Korea
| | | | - James F Phillips
- Mailman School of Public Health, Columbia University, New York, USA
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Awoonor-Williams JK, Apanga S, Bawah AA, Phillips JF, Kachur PS. Using Health Systems and Policy Research to Achieve Universal Health Coverage in Ghana. GLOBAL HEALTH, SCIENCE AND PRACTICE 2022; 10:e2100763. [PMID: 36109062 PMCID: PMC9476492 DOI: 10.9745/ghsp-d-21-00763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 05/31/2022] [Indexed: 11/15/2022]
Abstract
Ghana is positioned to become the first country in sub-Saharan Africa to implement universal health coverage based on nationwide expansion of geographic access through the Community-based Health Planning and Services initiative. This achievement is the outcome of 3 decades of implementation research that health authorities have used for guiding the development of its primary health care program. This implementation research process has comprised Ghana's official endorsement of the 1978 Alma Ata Declaration, leading to the institutionalization of evidence relevant to the strategic design of primary health care and national health insurance policies and services. Rather than relying solely upon the dissemination of project results, Ghana has embraced a continuous and systemic process of knowledge capture, curation, and utilization of evidence in expanding geographic access by a massive expansion in the number of community health service points that has taken decades. A multisectoral approach has been pursued that has involved the creation of systematic partnerships that included all levels of the political system, local development officials, community groups and social networks, multiple university-based disciplines, external development partners, and donors. However, efforts to achieve high levels of financial access through the roll-out of the National Health Insurance Scheme have proceeded at a less consistent pace and been fraught with many challenges. As a result, financial access has been less comprehensive than geographical access despite sequential reforms having been made to both programs. The legacy of activities and current research on primary health care and national health insurance are reviewed together with unaddressed priorities that merit attention in the future. Factors that have facilitated or impeded progress with research utilization are reviewed and implications for health systems strengthening in Ghana and elsewhere in Africa and globally are discussed.
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Affiliation(s)
| | | | - Ayaga A Bawah
- Regional Institute for Population Studies, University of Ghana, Accra, Ghana
| | - James F Phillips
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Patrick S Kachur
- Mailman School of Public Health, Columbia University, New York, NY, USA
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