Community-Based Health Planning and Services Plus programme in Ghana: A qualitative study with stakeholders in two Systems Learning Districts on improving the implementation of primary health care.

BACKGROUND: In 1999, Ghana introduced the Community-Based Health Planning and Services (CHPS) as the key primary health care strategy. In this study, we explored the challenges, capacity development priorities, and stakeholder perspectives on improving the CHPS concept as it has been fraught with a myriad of challenges since its inception. Our study is the outcome of the national programme for strengthening the implementation of CHPS Initiative in Ghana (CHPS+) introduced in 2017. METHODS: This exploratory research was a qualitative study conducted in two Systems Learning Districts (SLDs) of CHPS+ in the Volta Region of Ghana from March to May, 2018. Four focus group discussions and two general discussions were conducted among 60 CHPS+ stakeholders made up of health workers and community members. Data analyses were conducted using conceptual content analysis. Statements of the participants were presented as quotes to substantiate the views expressed. RESULTS: Negative attitude, high attrition, inadequacy and unavailability of health professionals at post when needed were challenges associated with the health professionals. Late referrals, lack of proper community entry and engagement, non-availability of essential logistics, distance of CHPS compounds from communities, and inadequate funding were challenges associated with the health system. Lack of community ownership of the CHPS programme, lack of security at CHPS compounds, and late reporting of cases by the community members were also realised as challenges emanating from the community members. Priority areas for capacity development of health workers identified included logistics management, community entry and engagement, emergency delivery, managing referrals at the CHPS level, and resuscitation of newborns. CONCLUSION: Health-worker, community, and health systems-based challenges inhibit the implementation of CHPS in Ghana. Capacity development of health professionals and continuous community engagement are avenues that can improve implementation of the programme.

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.

The Ghana vasectomy initiative: facilitating client-provider communication on no-scalpel vasectomy.

OBJECTIVE: In 2003-2004 and 2007-2008, an initiative was implemented to improve client and provider knowledge and acceptance of no-scalpel vasectomy (NSV) in Ghana. METHODS: At eight facilities, physicians were trained in NSV and staff received training in the provision of "male-friendly" services. Health promotion activities provided NSV information to prospective clients. Client-provider communication was assessed via a mystery client study (n=6). Knowledge and acceptance of NSV among potential clients were assessed with baseline and follow-up surveys (each n=200) in 2003-2004 and three follow-up panel surveys in 2008 (each n=240). RESULTS: Trained health staff exhibited improved attitudes and knowledge regarding NSV. Mystery clients reported receiving accurate, nonjudgmental NSV counseling. Awareness of NSV among panel respondents doubled from 31% to 59% in 2003-2004 and remained high (44%) in 2008. The proportion of men who would consider NSV increased from 10% to 19% in 2007-2008. NSV procedures increased three-fold from 2003 (n=26) to 2004 (n=83) and 2007 (n=18) to 2008 (n=53). CONCLUSION: Provider training in client-centered services, coupled with targeted health promotion, improved client and provider knowledge and acceptance of NSV in an African context. PRACTICE IMPLICATIONS: Complementary, sustained provider training and health promotion are needed to maintain NSV service quality and acceptance.