Ghana has a long experience with evidence-based health systems development. During the early 1990s, debate about practical means of achieving the World Health Organization’s goal of “Health for All by the Year 2000,” led the Ministry of Health to implement an experimental maternal and child health program in Kassena-Nankana District of the Upper East Region (UER), Ghana’s poorest region. The program, known as the “Navrongo Experiment” was based at the Navrongo Health Research Centre, which due to its past involvement in international public health research, had a Demographic Surveillance System (DSS) that regularly conducted continuous monitoring of mortality, morbidity, and fertility dynamics in this largely rural Sahelian area. By 1998, preliminary results of the Navrongo experiment had begun to demonstrate that the project would have an impact. In the initial five years, fertility declined by about a birth from a total fertility rate of 5.5 and the maternal mortality ratio declined by 40% [1–5]. By the end of project monitoring in 2003, childhood mortality was reduced by 68% in communities where nurses were based while levels remained relatively unchanged in comparison areas.
The program’s success was based on at least two key features. First, it offered life-saving services delivered in a convenient, low-cost, and effective manner. Estimates derived during the Navrongo experiment suggested that the program, if faithfully scaled up, would add only $2.92 per year per capita to the revenue budget to launch, and an additional $1.92 per capita to current spending to sustain over time. Second, through community mobilization activities — especially with men — the program built a climate of trust between community health workers and extended families. Whereas clinical workers are required to extract fees from parents at the time of care, the community engagement system enabled community-based workers to trust clientele to eventually reimburse the system for pharmaceutical costs, even if families lacked cash at the time of care. This “trust as insurance” system ensured that extended families could be trusted to support emergency health care costs. Moreover, community engagement overcame “gatekeeping” of women’s health-seeking behavior. When women and children become ill in profoundly gender-stratified societies like those of northern Ghana, they are often denied the timely provision of simple, life-saving interventions because their elder women or male relatives are reluctant to allow them to seek care immediately . This problem is particularly constraining for family planning services. Through community meetings, peer education, and other interventions, the Navrongo model helped relax these constraints on women’s behavior.
Despite the success of the Navrongo Experiment, the policy relevance of results was questioned by many district, regional, and national program managers. To address this skepticism, the district health management team (DHMT) from the Nkwanta District of the Volta Region launched a replication trial of the Navrongo experiment . Implementation research showed that immunization coverage, service volume, and family planning acceptance replicated the Navrongo model [4, 5]. In 2000, in response to this demonstration, scaling up of the Navrongo model, now called the Community-based Health Planning and Services (CHPS) Initiative, was adopted as national policy .
The CHPS initiative
The primary staff resource for Community-based Health Planning and Services
(CHPS) are nurses, termed community health officers (CHOs), who spend 18 months in training schools and carry out an additional six-month internship for developing community liaison skills. CHOs are provided with essential equipment and assigned to health posts where they live and conduct doorstep services. This involves treatment of malaria, acute respiratory infections, and diarrheal diseases termed integrated management of childhood illness (IMCI). CHOs also provide comprehensive childhood immunization and family planning care for oral, injectable, and barrier contraception. CHOs live and work in health posts built with donated materials and the labor of community volunteers, and they are provided with a motorcycle. As resources become available, health posts are often upgraded or reconstructed as permanent structures that replace makeshift community-provided facilities. Volunteers care for diarrheal diseases, but they are mainly health promoters and referral agents who balance nurse outreach to women with a focus on the information needs of men and organizational activities. To support their work, these volunteers receive a bicycle.
CHPS occupies the “ground level” of the health system. Both CHOs and community volunteers provide services at the doorstep and at community health posts. As in the rest of the Ghana Health Service (GHS), trained paramedics provide care at sub-district health centers, serving roughly six to 10 villages or 20,000-30,000 people, and clinicians provide surgical and other specialty care at district hospitals. Of the three districts– Garu-Tempane, Bongo, and Builsa – in the Ghana Essential Health Interventions Project (GEHIP) , Garu-Tempane lacks a hospital and medical coverage. Financial management and policy guidance is provided by a district health management team comprised of a District Director of Health Services and officers responsible for disease control, nursing, clinical operations, and nutrition. Supplemental funding for CHPS is sometimes provided by Regional Health Administration (RHA) resources, but uniform standards for such support is lacking.
The Navrongo experiment demonstrated the limitations of basing child survival programs on access to commodities and/or clinical care alone. In one of the three study areas, briefly trained, unpaid volunteers were deployed to refer cases and provide antipyretics, vitamins, and other non-prescription drugs. Over the short-term, child mortality actually rose in this area compared to a control area where no interventions were offered, other than those routinely offered by the GHS. Research subsequently showed that syndromic intervention by credible but poorly trained volunteer workers delayed parental health seeking for effective curative care . Only when comprehensively trained and fully paid nurses were posted to these areas did child mortality begin to fall substantially . This crucial lesson still has yet to be internalized by many international donors, many of whom continue to favor interventions based on the distribution of simple commodities or health promotion by untrained volunteers alone, eschewing more substantial health system interventions because they seem complicated and expensive .
Properly trained and equipped community health workers can have health equity effects. In the Navrongo experiment, nurse care offset the detrimental effects that low parental-educational attainment and relative household poverty had on immunization, health-seeking behavior, and child survival. Volunteer services had no comparable equity effects . However, if nurse-provided community-based care was combined with health promotion activities of volunteers, family planning gained credibility and both fertility and maternal and child mortality declined. Thus, the combined approach was adopted as the organizational model for CHPS.
Ghana aims to expand CHPS to all communities by 2015 with finances provided largely through government resources, although there is no health-sector budget provision for the cost of launching CHPS. Additional support is provided by NGOs, district assemblies, and the global community. Facility costs, equipment costs, and special start-up investments are not routinely available. But, flexibility for financing these costs exists in the development sector. In particular, development revenues of the World Bank, the European Union, and some bilateral donors are committed to flexible revenue accounts managed by decision makers with the District Chief Executive and District Assembly development. Whereas policies of the “Sector Wide Approach” once provided flexible revenue to district health managers, all fiscal flexibility is now managed by district political authorities. This pool of resources is combined with the government of Ghana’s flexible financing as well as by communities in the form of material and volunteer labor. Taken as a common fund, this source of revenue provides crucial district development resources that are external to the health sector but could be used to finance the essential $2.92 per capita in CHPS start-up costs. Since only about $14 per capita is available for all health expenditures combined, any meaningful contribution to the $2.92 per capita represents a major catalytic investment in CHPS expansion . However, district officials must decide to make and sustain this investment, despite competing demands on the development budget from other sectors.
Where CHPS leadership is well-articulated, district political commitment has directed resources to the $2.92 per capita incremental start-up costs. Exchanges between districts have been critical to demonstrating effective means of developing this commitment. By 2008, CHPS implementation had commenced in all of Ghana’s districts, but scale-up within districts had stalled or was incomplete nearly everywhere. CHPS, as it was originally envisioned, was reaching only 12% of Ghana’s households . Where Regional Health Administration (RHA) support involved the financing of exchanges between districts, there was active engagement with political and development authorities. Routine discussion of CHPS at staff meetings led to a small investment in CHPS and generated pilot implementation zones within districts. These demonstration communities, in turn, were instrumental in establishing a process of CHPS implementation within a given district that was rapid and straightforward. The Nkwanta experience showed that proper introduction within a given district, with strategies for community engagement, could catalyze political and NGO investment in scale-up. Through peer-to-peer exchanges, district leaders who had implemented CHPS successfully were able to persuade those in other districts to do the same, but this “catalytic leadership” was hard to define programmatically and has not been instituted on a national scale . Donor support for some aspects of CHPS expansion has been generous but has tended to support technical assistance and workshops rather than the political mobilization that seems necessary to transfer implementation capacity from one district to another.
The fundamental problem was that CHPS was originally conceived as a community-based trial focused on identifying the best way of delivering services and sustaining community engagement for primary health care, rather than a systems initiative that involved interventions for developing district and regional leadership. Research on CHPS was focused on identifying the best way of delivering services and sustaining community engagement for primary health care. However, scaling up CHPS is a district systems issue and requires improved capabilities in regional and district management, planning, budgeting, and resource development. This, in turn, requires political mobilization beyond the community level.
In addition, fidelity to the original CHPS model developed at Navrongo has dissipated with passing time — a scaling-up phenomenon noted elsewhere [11–13]. For example, the Navrongo model encouraged communities to construct health posts for CHOs from donated materials with volunteer labor. Construction of permanent facilities was meant to be a reward for this community activity. However, some district managers delayed nurse deployment until revenue became available for financing outside contractors to construct health posts. Consequently, construction has become a constraint to implementation rather than an incentive for community action. Using funds to hire outside contractors also substantially raised the potential cost of scaling up, creating a further disincentive for donors and others to support the project.
The package of services was also often incomplete and proven life-saving components were needlessly excluded from the regimen. For example, supervision of nurses and volunteers was inadequate in many districts and information systems were so cumbersome that they were useless to CHOs. Another problem was that district leadership often prioritized ambulatory clinical care of adults rather than building community and political engagement to encourage community-based preventive health services and early treatment of the leading causes of childhood morbidity. In addition, owing to official National Nurse Midwife Council objections, CHO training excluded emergency obstetric care — life-saving skills, such as the management of asphyxiation and haemorrhaging, and proven approaches to saving newborn lives. In CHPS zones that were as yet incomplete, IMCI services were often inaccessible because there was no CHO. Volunteers might have been able to provide some of these services, but since they were often poorly trained and supervised, the GHS did not allow them to provide antibiotic therapy.
Thus, despite evidence that community-based primary health care was scalable and affordable, health conditions remained needlessly poor. According to national statistics at GEHIP baseline, infant mortality was 50 per 1000 live births and under-5 mortality was 80 per 1000 person-years . However, roughly comparable rates applied in the Upper East Region (UER), (46 per 1000 live births and 78 per 1000 person-years, respectively) even though this is the poorest part of the country. Research in progress suggests that the wider implementation of CHPS in a way that was faithful to the original Navrongo experiment largely explains this apparent paradox.