Community-based Health and Planning Services: Decentralizing Ghana’s Health System

GUJHS. 2008 Apr; Vol. 5, No. 1.

Stephen Russell
Georgetown University
Dodowa Health Research Centre, Ghana

Introduction
Ghana is an affable sub-Saharan African country that faces health issues similar to other African nations. Ghana’s population of 22.4 million suffers from high maternal and child mortality, diarrhea, malnutrition, HIV/AIDS, malaria, and other endemic diseases. Barriers to solving these problems include poverty, low education and literacy rates, lack of organization in the health system, poor infrastructure, inequitable health financing, and dearth of skilled health personnel (1, 2). Most of Ghana’s most impoverished individuals live in remote villages, where it is particularly difficult for Ghanaians to receive proper and timely medical attention. About 60% of Ghanaian’s participate in subsistence farming and an astounding 80% work in the informal sector as farmers, fishermen, or roadside vendors (3). Ghana has adopted the Community-based Health and Planning Services (CHPS) system to increase access to and use of health services in remote communities. This revolutionary system brings trained health care workers directly into the communities and rallies community support behind them to ensure the system’s acceptability and sustainability. CHPS offers the best opportunity for more effective and efficient health care in rural communities in Ghana.

Health System Overview
The health system has a traditional top-down structure, with the Ministry of Health (MOH) determining health policy. The Ghana Health Service (GHS) works closely with the MOH, transforming policy into procedure. The GHS further breaks into regional, district, sub-district, and community levels. All levels of Ghana’s health system are directly responsible for service provision except the MOH, which is solely a governing body. The Ghana Health Service distributes resources, monitors all levels of the system, provides training for skilled nurses and doctors, and conducts research and evaluation. There are ten regional offices responsible for maintaining hospitals and monitoring the districts health administrations. The district and sub-district levels are responsible for implementation of MOH policies, baseline data collection, in-service training, and providing care at the community level. At the community level, great strides have been made in recent years; the government has committed itself to moving care from established facilities (of which there are woefully few) directly to communities (1) (MOH, Ghana 2006). This concerted effort was outlined in the country’s Programme of Work (POW) for 2002-2006. The POW has been the backbone of MOH and GHS activities for the past ten years and will continue to be influential as a new five-year plan is embarked upon this year.

Stretching from 2002-2006, the POW focused on eliminating inequities in access, improving health financing, strengthening partnerships with international organizations, and reducing the burden of disease throughout the country (1). An important goal for the POW was to establish a national health insurance scheme to relieve the disproportionate burden carried by the poor in the old cash-and-carry system. The scheme’s implementation, however, has been wrought with difficulty and remains in its infancy. Most of the goals of the previous POW have spilled over into the new POW.

The new POW, valid until 2011, aims to strengthen the gains made in the past five years, and increase the capacity of the health sector (2). The new POW marks a transition to a focus on preventive care. Promoting active, healthy lifestyles will address Ghana’s rising incidence of non-communicable disease, an issue that until now has been less emphasized that curative care (2). The new emphasis on health promotion and disease prevention should create healthier Ghanaians, making them less susceptible to mortality from common communicable diseases and slowing the rising tide of non-communicable diseases. The new POW will accomplish this transition, as well as continuing to provide better all around care at the community level, with the help of the Community-based Health and Planning Services (CHPS) system.

CHPS is the Ministry of Health’s plan to shorten the gap between health access for the increasingly urbanized south and the agrarian north. Even within districts, there is often a spectrum between urbanized areas and remote communities. The CHPS system decentralizes Ghana’s health system by locating more resources directly into communities and involving communities in important health decisions. This empowers communities with choices about health care and gives individuals the opportunity to receive quality and prompt treatment from the health system. The CHPS system is the system of the present and the future for Ghana; it represents an opportunity for the country to provide quality health care for all of its citizens, a goal which has long been sought by the government and a crucial step for Ghana’s development.

Community-based Health and Planning Services
Background
Before CHPS was used as Ghana’s strategy for decentralizing the national health system, it was a pilot project in the northern region of Navrongo. In Navrongo, a Community-based Health and Family Planning (CHFP) initiative was established to decrease high infant mortality and high fertility rates (4). The program was first implemented in the Kassena-Nakana district, where infant mortality was 120 per 1,000 live births, the total fertility rate was above 5%, immunization levels were low, and contraceptive use was lower than 4% (5). The Kassena-Nankana district was illustrative of a larger problem, the lack of proper health care in poor rural communities. Communities like those in this district had literacy rates as low at 48% among women and urbanization in only 10% of the district (3,4). The Kassena-Nankana district was representative of how the health system bypassed rural communities, making it an excellent setting to test the effect of a community-based health care system.

Navrongo was chosen as the site backed by the MOH, who was looking for a scientifically proven way to decentralize the health system; CHFP was that project. MOH planned to take the lessons learned from the CHFP project and nationalize it into CHPS. Navrongo was ideal for its proximity to communities who had some of the worst health statistics in the country; it was posited that a successful program implemented in Navrongo could be replicated anywhere. Another factor making Navrongo an ideal site was the established research center. The research team already had a demographic surveillance system collecting baseline data of basic health indicators (6). Additionally, the Navrongo research center had completed a Panel Survey System (PSS) recording data specifically focused on family planning issues (6). CHPS could be implemented under the auspices of established and respected researchers where any success or failure could be easily and accurately marked. The Navrongo site specifically separated the research side from the implementation side to ensure that CHPS could feasibly be implemented in other districts with the same amount of resources available to Navrongo (7).

Identifying the Problem
Observing the present health care system, researchers at Navrongo identified the duel problem of underutilized nurses at health care facilities and individuals in rural communities unable or unwilling to go to health care facilities. The communities were simply too far and the people too poor to travel to health care facilities. Also, the harm caused by carrying or carting a sick child might kill them before ever reaching care (8). The Navrongo researchers thought it possible to address the issue of limited access to orthodox health care in rural communities by moving nurses directly into community settings.

Another problem was the continued importance of traditional healers and other sources of unorthodox health care. Rather than making the long and costly trip to orthodox health care, community member thought it just as effective to go through traditional avenues to deal with health issues (8). Navrongo researchers proposed that some sort of social intervention was necessary to ensure that communities would accept orthodox health care.  Navrongo identified limited access to health care and lack of social involvement in health decisions as barriers to creating a better system of providing health care at the community level.

The Test
CHPS began as an experiment to determine whether relocating health care workers from clinics, where they were being under utilized, to communities would produce greater health (4). This was termed the MOH dimension of the test. In addition to moving nurses to live in rural communities, the MOH dimension included a plan for building a community health compound. The nurses at the community level would be housed in a community health compound, created with the resources and labor of the community.  The community health compound represents efficient and effective care and ensures sustainability in the community. The MOH dimension gives the community access to highly trained health personnel, a discrete health care center, and it also creates a direction line between the community and the rest of the health care system through the nurse (9). Before forcing the community to create a community health compound and then stationing a nurse there, community sensitization and inclusion is necessary.

It is not difficult to imagine that putting trained nurses directly in communities produces better health outcomes; the revolutionary idea of the CHPS system is the prominence of the Zurugelu dimension. The Zurugelu dimension involves community leaders and community members in health care decisions to create a more effective and sustainable system. This type of system increases the level of flexibility at the community level for unforeseen new challenges. While it has long been believed that including individuals in their own health planning is an effective way of bringing health care to communities, it has rarely been systematically tested and never in Ghana (9).  The idea in the Navrongo experiment was to use the influence of community elders and leaders by including them in the planning process of their own health care system. If community elders approved the use of orthodox medicine, then it was hoped that individuals in the communities would follow the elders’ example and use orthodox health more often (4). More and more, individuals in the community would come to understand the benefits of orthodox health; this is the idea of “social diffusion” that the Zurugelu dimension aimed to generate (10). Mobilizing local social networks and giving communities control over their health care options encourages orthodox health care in the most socially acceptable and appropriate way, giving the communities a stake in their own healthcare and thus cultivating an effective, flexible, and sustainable system.

The test for the CHPS system was a four celled experiment using four different strategies in four different communities: one received the regular MOH offered package that it had been receiving (which basically meant only access to the district clinic), one community was tested with the “Zurugelu dimension” only (community volunteers), one received the “MOH dimension” only (nurses at the community level without direct community support), and one community received both the “Zurugelu dimension” and the “MOH dimension”. Volunteers are the backbone to the Zurugelu dimension of CHPS; they are key advocates in the community (4, 6). It was thought that this last combination would give the best results, and it is the one that CHPS ultimately implemented.

Implementation
Volunteers are respected members of the community, nominated at community meetings; the community members vote amongst themselves (11). To prepare them for service, volunteers receive two-weeks of training on primary health care, hygiene, treatment of minor ailments, family planning, sexual transmitted infections, and several endemic diseases (8). Armed with this knowledge and a few essential drugs, volunteers return to their communities to check on children and mothers who are ill or pregnant, and to educate villagers about health, hygiene, and sanitation (8). Any community-related issues are taken to the chief, elders, or community council for discussion. A communal decision is established; the micro-health system in the community evolves from this learning-by-doing method.

The package of treatments and drugs available to communities through the volunteers and nurses is comprehensive. The volunteers carry drugs that are easy to prescribe and use: paracetamol for pain, oral rehydration salts for diarrhea, multivitamins, condoms, other contraceptives, and first line malaria drugs (12). Since free drugs are unfeasible, communities decide a reasonable price for the drugs, and the system is sustainable (8). Community health nurses come to the field armed with advanced drugs, immunizations, and modern contraceptives. These nurses also need a motorbike for transportation, a radio, pens and paper, and other necessities for the community health compound (12).  Armed with these necessities, the nurses and volunteers are prepared to deal with a myriad of problem at the community level, and are able to make necessary referrals to district hospitals or nearby health centers.

Results and Implications
The CHPS experiment showed conclusively that the best intervention at the community level combines the MOH dimension and the Zuruglu effect. They learned that community volunteers, no matter how dedicated, were no substitute for a trained nurse. Nurses allow for greater coverage of immunizations, ambulatory services, and referrals. In areas where the Zurulegu dimension was implemented without the MOH dimension, total fertility rates actually increased. This highlights the importance of skilled health care workers in a community, and relegates the community volunteers to disease prevention, health promotion, and some types of primary care. The Zurugelu dimension greatly supported the MOH dimension and made CHPS more feasible.

The CHPS experiment in Navrongo achieved some success but was plagued by uncertainty and uneven results. Specifically within family planning, however, results were strongly encouraging. Within the first year of both the MOH dimension and Zurulegu dimension, the total fertility rate dropped by about one half of a child; this number continued to drop in subsequent years but not by a consistent amount. This translates to a 15% drop in the fertility rate in only 4 years (13). Also, women who were in contact with community health nurses were 2.6 times more likely to continue with modern contraceptive use.  It was found that 59% of women in 1999 expressed a desire to space out their births, up from 42% in 1993 (13). This statistic suggests that fertility rates will most likely continue decreasing. These statistics illustrate the usefulness of including family planning as a key element in a CHPS system.

Similar progress was made in reducing child mortality, although some statistics point of the lack of breadth in the CHPS program offerings. Children exposed to the MOH and Zurulegu dimensions had a 12% lower mortality, and children between the age of 24-59 months who had contact with communities health care workers for two years had a 60% decrease in mortality (5). Infant mortality, as well, dropped from 141 to 96 per 100,000 live births (13). While these numbers are encouraging, there was no change found in neo-natal mortality, illustrating a need for emergency obstetric care and more births attended by a trained health care worker (5). Another worrisome statistic is that, during the CHPS program, HIV infection rates grew from 2.4% to 5.1% in the period of only 12 months (5). This highlights the potential for widespread transmission of HIV/AIDS and could present a major hindrance not only to the CHPS system, but also the entire Ghana health system.

Taking CHPS Nationwide
After success in Navrongo was repeated in the southern Nkwanta District, the MOH and GHS nationalized the CHPS program. Even though CHPS was approved for implementation in 1999 in all districts, by 2003 only 5% of Ghana’s population was covered by a CHPS system (10). Of the 110 districts, only 30% had implemented any part of CHPS in 2000 (10). The greatest barrier to nationalizing the CHPS program has been an implementation gap at the district level; 85% of districts have reached the planning stages of CHPS but because of uncertainty, lack of resources, or other reasons the implementation stage has not begun (14).

One of the greatest problems facing the inception of new CHPS programs is nurses’ aversion to working in rural areas. There are few incentives for nurses to move themselves and their families to rural areas, particularly when prospects in the private sector are more attractive. Navrongo is addressing this issue by constructing a school to train nurses on site (14). Navrongo has also responded to holes in their CHFP/CHPS system by introducing interventions for emergency obstetric care and female genital mutilation care (5). These issues are a long way off for most districts that are struggling to work with their District Assembly and the District Health Management Teams to get CHPS off the ground.  It is now in the hands of the health system at the National, Regional, and District levels to take the lessons learned from Navrongo, tailor them to specific communities, and begin implementation. It is yet to be seen how well CHPS will be integrated into the Ghana health system, but it is the most proven and most effective program as yet to move health services from stagnant facilities to dynamic provision in the communities at the doorsteps of clients.

CHPS is a dynamic framework that requires dedication and hard work from the Ghana Health System at all levels, as well as in communities advocating for themselves. CHPS creates a working micro health system in communities that is flexible and able to grow horizontally to include more interventions. Once CHPS programs get off the ground they should be sustainable; if this is the case than Ghana’s prospects look bright.

Ghana and Beyond?
The CHPS system is one of the first of its kind, but the need for community-based health action is not unique to Ghana. Many developing countries face the same daunting maternal and child mortality rates, high fertility rates, low immunization coverage, and generally poor health outcomes. The Navrongo experiment has attracted international attention as a useful way to combat these issues by bringing health to the doorstep of the least fortunate. Navrongo has hosted delegations from Nigeria and Burkina Faso in 2002 and 2004, respectively, who have come to learn from CHPS (13). Other countries in West Africa and beyond are realizing the gains to be made from mobilizing community momentum to drive health. The Navrongo experiment serves as a guide for countries throughout the developing world to realize health for all.

Case Study: Dodowa Health Research Centre Malaria Pneumonia Program
The implementation of CHPS has been slow in some areas of Ghana. One of the advantages to the CHPS system is its versatility, however, and some district health teams have adopted facets from the CHPS experiment in their own programs. The Dodowa Research Centre’s Malaria Pneumonia Program is one such example; the program trains and uses community-based agents to distribute malaria medication in rural communities. While the Malaria Pneumonia program is not a CHPS program per se, it uses lessons learned from the Navrongo experiment to enhance the effectiveness, efficiency, acceptability, and sustainability of its program.

The Dodowa Health Research Centre is similar to the Navrongo Research Centre.  Dodowa has set up a demographic surveillance system, and has been working to implement CHPS throughout its district. Dodowa has worked closely with Navrongo, and has learned quite a bit from the work being done there. The Malaria/Pneumonia study of the Dodowa research centre uses community-based agents, as exemplified by the Zurugelu effect of CHPS, to encourage families to take early action against fevers. The Malaria/Pneumonia program mimics lessons learned from the Navrongo experiment in their use of film as a teaching tool, community-based volunteers, and the ideas of social diffusion and community action (15).

The purpose of the program is to reduce under 5 mortality by teaching community management of fevers and distributing anti-malarial drugs (16). The main agents of change in the community are the community-based agents, volunteers chosen by their communities. CBA’s are trained by the Dodowa research team, and then reintroduced into the community with malaria drugs and knowledge on Pneumonia and Malaria (17). While the program is mainly designed to distribute drugs, it has learned from the Navrongo experiment that this is done in the most effective and sustainable way when there is community action and acceptance backing the intervention. The Malaria Pneumonia project adapts some of the teaching points of the Navrongo experiment about community sensitization and inclusion and focuses on community action and acceptance.

To initiate community entry, a team appeals to the chief of the community or the elders and presents the program (16). If the chief or elders accept the proposal, then a meeting is planned and the community is informed, either by the chief or by the Dodowa research team using a car with a loudspeaker attached to it. The loudspeaker invites all members of the community to the meeting. At the meeting, the community selects their community-based agent, someone whom they trust to provide quality care. The Dodowa research team then trains the individual on characteristics of malaria and pneumonia and how to recognize and treat fevers; later, the community-based agent is reintroduced to the community as a health contact (17). The re-introduction of the CBA coincides with a video presentation by the Dodowa research team showing early signs of fever and encouraging them to seek the CBA for medical attention and possible referral (16).

This program mirrors the lessons learned from the Navrongo experiment and, although it is not an exact replica of CHPS, it uses the same type of community-based intervention to improve health care at the community level. By convening the community together, asking them questions, and showing them the video of proper behavior the Malaria/Pneumonia study replicates the idea of “social diffusion” popularized by the Navrongo experiment (10). The belief is that behavioral change occurs through social interaction. The Malaria/Pneumonia video emphasizes the importance of orthodox health centers in treatment of fevers. It also schools men on their vital role of managing the house and family when the wife has taken the child to the CBA or the clinic (8).  Another section of the video shows one mother telling another mother about the great job that the CBA did in caring for their kid; she encourages the mother to take her ill child to see the CBA (17). These types of social interactions encourage social diffusion and will hopefully encourage communities to use orthodox health avenues.

It is an encouraging sign that, while CHPS may not be implemented completely in every district, centers such as Dodowa are finding ways to deliver necessary health interventions at the community level with the CHPS example. Like the Navrongo experiment, Dodowa’s Malaria and Pneumonia program initiates community action, involves the community in decision making for the program, and uses community based agents to provide close care.  CHPS can be initiated in districts by building on just one or two programs like the Malaria and Pneumonia program before district teams have the ability and confidence to scale up CHPS operations. The Malaria Pneumonia program is safe, efficient, and acceptable to the community, but as the study is in progress it is yet to be seen how effective the intervention is in reducing under 5 mortality.

Conclusion
The Ghana health system works like many health systems in its top- down approach. The Ministry of Health and Ghana Health Service run policy formation and service provision. In recent years their focus has shifted towards grassroots programs starting from the community level. These new programs, exemplified by the CHPS system in Navrongo, provide orthodox health care directly to the many rural areas of Ghana. Some success has been shown with CHPS, although it has taken time and more work needs to be done to firmly establish CHPS in districts throughout the country. The government embarks upon a new five-year program starting this year in an attempt to strengthen the CHPS community-based health programs and to increase efficiency and effectiveness in the health sector in general. The next five years will be a critical period for Ghana’s health system as it scales up operations of CHPS to provide all of its citizens with proper and timely access to quality health care.

References
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16. Dodowa Health Research Centre, “Malaria Pneumonia Study: Home and Community Management of fevers in children under five in Dangme West district.” Powerpoint Presentation. August 2007.

17. Personal observation of Dodowa Malaria/Pneumonia Field Team, Sept. 5 and Sept. 12 2007.

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