The Methodist Church Ghana

and
Community-based Health Planning
and Services (CHPS) -
A Strategy to Achieve PHC:
Dr. Alex Korshie Nazzar; MBChB, MPH
Annual Review Meeting of the
Methodist Health Service on 5-6 March, 2014, Freeman Guest
House (opp. Wesley College), Kumasi
 The Goal of Primary Health Care
• “The goal of the Primary Health Care system is to
achieve an optimal physical, mental and social well-
being of the Ghanaian people. It is estimated that
up to 80% of illnesses could be prevented by the
combination of improved nutrition, adequate clean
water supplies, education on personal hygiene,
family planning, vaccination services, treatment of
common ailments and injuries. These are the main
activities of the Primary Health Care System.

Dr. E. G. Beausoleil: Former Director of Medical Services

exit
 What Primary Health Care means
• Primary Health Care does not mean the provision of medical
miracles for all existing ailments. Nor does it mean that nobody
will be sick or disabled any more.
• What it does mean is that health begins in your home, in your
schools, in your offices, factories and markets. It is there, where
people work, study and live that good health is made or broken.
• It does mean that people become aware of the power and
responsibility they possess to shape their lives and the lives of
their families towards healthy living.
• Primary Health Care means that people use better means of
preventing diseases and healthier ways of growing up.

Dr. E. G. Beausoleil: Former Director of Medical Services

exit
 Structure of the PHC Systems
• Ghana’s PHC System was designed as 3 tiered
system at the District Level
– DHMT at the District HQ working with Local
Government and other sectors
• Responsible for Planning Monitoring and Coordination
– SDHT at the Health Centre level for operational
implementation
– Community level organized to bring services close
to client
 At the Community Level
The challenge had always been at the community level;
The Health Centre is Far Away from major roads;
Remember DANFA, BARIDEP, BAMAKO Initiative!
Health Centre

Wide Catchment Area; Poor roads; Few vehicles, infrequent

movement; Difficult terrain; High levels of Poverty
 To address this inequity in access…
• MoH organized research to test out a most
appropriate method to provide health services at the
community level;
• Referred to as the ‘Navrongo Experiment’ the research
showed that “…placing nurses in community locations
reduced childhood mortality rates substantially over 8
years and accelerated progress towards the childhood-
survival MDG in the two study areas relative to trends
observed in comparison areas1”.
• This strategy was packaged together and called CHPS
1
Rapid achievement of the child survival millennium development goal: evidence from the Navrongo experiment in Northern Ghana:
Fred N. Binka, Ayaga A. Bawah, James F. Phillips, Abraham Hodgson, Martin Adjuik and Bruce MacLeod
Tropical Medicine and International Health; volume 12 no 5 pp 578–583 may 2007
 What does it mean?
• Two main things have to be planned for in detail:

a. Planning with the community members how to

establish health consciousness at the
community level where traditionally there are
no formal health structures
b. Planning with the community members how to
design and deliver appropriate health services
at the community level
 Why the emphasis on rural community?
• Because the rural community is very different from the cities and
towns
1. They constitute more than 65% of the settlements in the
country
2. The people do not have many resources/they are deprived
3. The trained health workers do not normally like to work in the
poor rural areas
4. Cars and vehicles are few - Distances are therefore far!
5. The roads, even where they exist are not motorable!
So the way to arrange and deliver services is not the same as in
towns and cities
• So, exactly what did the experiment in
Navrongo do?
 The Health Worker / Community interphase
Within the CHPS Zone

2. CHMCs
exit

3. Community
Health 1. Mobilized
Volunteers Communities

1. Mobilized Communities in a
4. CHPS Compound
CHPS Zone with …
With CHO
2. Community Health Management
Communities and …
3. Community Health Volunteers …
4. … and procure CHPS Compound for CHO
residence and treatment of minor ailments
 Bridge the Access and Information Gap
• Re-orient and retrain the Health Workers as CHANGE AGENTS;
• Engage and Mobilize the Communities and the Local Government;
• Allocate reoriented and retrained Health Workers in the communities;
• Deliver basic package of health services H’se to H’se;
• Emphasise Basic Maternal and Child Health Care Services (IMCI)
• Arm them with Messages for Health Promotion, Family Planning, and
Referrals where needed.
• Strengthen the H/C to supervise
Health
Centre

Community
Health
Compound
(CHC)
Demarcated CHPS
Zones
The Ghana Health Service did this
from the point of view and with
the capacity of a Service Provider!

Operations Research
and with
Very good results!
 Assessments of the Implementation
Title Year Authors
1 In-Depth Review of the Community-based Health Planning and Services April 2009 Prof Fred Binka
(CHPS) Program et al
2 Repositioning CHPS – Challenges and scaling up strategies – Report on July 2009 By Nana
stakeholders meeting to review proposed policy change of Community- Enyimayew et al
based Health Planning and Services– draft report

3 Brief on Status of CHPS implementation Nov 2012 MoH

4 Evaluation Report on Scaling up of CHPS implantation in the Upper Dec 2009 JICA, MoH and
West Region GHS jointly
5 Definitions for Community-based Health Planning and Services August Dr. Frank
2010 Nyonator
6 What works and what fails – Findings from the Navrongo Community August to NHRC
Health and Family Planning Project – Vol 1 Dec 2001

7 The Ghana Community-based Health Planning and Services initiative 2005 Nyonator et al
for scaling up service delivery innovation

8 Lessons learned from scaling up the Community-based Health Program 2013 John Koku
in the Upper East Region of northern Ghana Awoonor-
Williams et al
 Major and Consistent Findings
• Rate of rolling out CHPS is stalling;
• Nature of CHPS is changing over time –
turning more and more into mini clinics;
• Community Entry and Engagement is no more
effectively done in many cases;
• The role of the communities as active
participants in the process is diminishing;
• Many District Assemblies are not as involved
in CHPS as expected
 After
Over Ten Years of Implementation

Time to Situate the CHO

Within
The Community Health System
 LEGISLATIVE FRAMEWORK
The constitution of the Republic of Ghana in Section 240 (1) states:
• “Ghana shall have a system of local government and administration which,
shall as far as practicable, be decentralized”.
• Section 241 (3) reiterates that subject to this constitution, a District Assembly
shall be the highest political authority in the district, and shall have
deliberative, legislative and executive powers”.

Further legislative frameworks include:

• The Local Government Act, 1993 (Act 462) - provides the core regulation for
the administration of local governments in Ghana
• The National Development Planning (System) Act, 1994 (Act 480) - lays out the
development planning functions of MMDAs
• Community Water and Sanitation Act 1998 (Act 564)
• Local Government Service Act, 2003 (Act 656)
• Local Government (Departments of District Assemblies) Commencement
Instrument, 2009 (L.I 1961)
 The Basic Mandate of Assemblies
• Under the assembly system, local authorities
have considerable powers.
• Acts 462 and 480 designate the assembly as
the local development planning authority.
Section 10 of Act 462 identifies the functions
of an assembly, and in
• Subsection 2 (c): Formulate and execute plans,
programmes, strategies for effective mobilization of
resources necessary for the overall development of
the district
 Relationships within the District
DCE/
District Assembly
DDHS/ Environmental
Hospital Presiding Health Officer
Member, Member of Parliament,
Coordinating Director, Assembly
SDH Members, Disease
Control
Health Education, Agriculture
Centre Officer
Water and Sanitation,
Plus Technical and Professional

Community Supporting Staf

Health System
Community Leadership and Membership
 Ref
Community Health Systems
District District /
District District
Assembly; Municipal
Hospitals Director of Soc. Sect.
Chief M&L
Health Sub Com
Services Executive
Ref
District
Sub- Planning
District Officer
Health Health Planning,
Centres Team SS&M

Clinical Determinants Track Social Determinants Track

Ref R
e
f

Comm. Service &

Com.
Trad. NGOs, Surveilla
Clinics CM CHO TBA CP Dev. Others
Ref Healers Officers nce

Prayer Env. &

Camps Sanit. Assemblyman
C H Vs Officers
The Perspective of the Policy maker
 Determinants of Health

HP Preventive Curative PhysioR Rehabilitation

P1 P2 P3 P4
Social Clinical
HEALTH DISEASE
Adapté de O’Neill et al., 2006
 Action on Health Determinants
HS Focus on ‘Ill Health’
(Preoccupied with Disease)
HP Preventive Curative PhysioR Rehabilitation

Action on SDH P1 P2 P3 P4

HEALTH DISEASE

Houéto., 2009
 Action on Health Determinants
Focus on Health
HS (Wellness)
(Preoccupied with Health)
HP Preventive Curative PhysioR Rehabilitation

Action on SDH P1 P2 P3 P4

HEALTH DISEASE

Houeto, 2009
 Goal
Improve the Physical Environment
 Of What use is a fully stocked and
well-equipped Pharmacy to people living here?
Means
Engage the communities more in health action

Community Meetings, Schools, Work Places, Homes

Environmental Sanitation
Water and Sanitation
 Consider these statistics!
University of Wisconsin Population Health Institute’s Schematic on Determinants of Heath
Premature Mortality (50%of Outcomes) = Years of Potential Life Lost
Health Outcomes
General Health Status (50% of Outcomes) = Self-reported fair or poor health

Health Care Access to Health Care

(10% of
Quality of Care
determinants)
Tobacco
Diet and Exercise
Health Behaviors
Health Alcohol use
(40% of
Determinants
determinants) High Risk Sexual Behavior
Violence
Socio-economic
Education
factors
(40% of Income
determinants) Social Disruption

Physical Air Quality

Environment Water Quality
(10% of
Programs Built Environment
determinants)
and Policies
Source: University of Wisconsin Population Health Institute
 The Challenge
How do we effectively
Establish and Manage the Health Worker / Community Interphase

• Who has the Comparative Advantage to do this: To animate, sensitize,

and galvanize the community?
– The Health Sector single-handedly? Or with
– The Local Government – and all the decentralized ministries?
• Who has the mandate, the competencies and the capacity to call ALL
the players to a round table, set the agenda and demand
performance?
• Who is best suited to provide technical advice, guidance and standards
for quality service to the people?
• What other significant roles are there and who should be involved?
What can the Methodist Health
Facilities do?

Based on Evidence!
 The Community levels know what they want!
Most Popular
Family Planning Counseling
Defaulter tracing and continuing
drug replacement
ARI in Children
Immunization and Vaccination
Services
School Health Services
Malaria case management
Nutrition Advisory Services and
Product Distribution
Growth Monitoring
Care of Children (1-59 months)
Care of Infants (7-28 days)
Diarrheal Disease Management
Distribution of contraceptive pills
and condoms
Post-delivery care of Mothers
Popular Least Popular
Care for neonates (0-7 Road Traffic Accidents (care of
days) victims/casualties)
Antenatal Care Services Hypertension Management
on expectant mothers
Antenatal Education in Ulcer Management
Groups
Dispensing of Antibiotics Dispensing Class C Drugs
Insertion and Removal of Minor Surgery (eg., Incision
Family Planning Implants and Drainage)
TB Treatment Diabetes Management
HIV/AIDS Treatment Dispensing of approved
traditional Medicines
Delivery
Yaws, Elephantiasis,
Schistosomiasis
Injuries and Poisoning
Obesity Management
 MCH Services
Child (C-IMCI)
Care of Infant 7 – 28 days;
Care of Under 5;
Mother Growth Monitoring;
Family Planning Services: CHO School Health;
Counseling; Methods Supply Immunization and Vaccination
Services;
ARI in Children

Cross-Cutting Services
Health Education/Promotion;
Malaria Case Management; Nutrition Advisory Services and Product Distribution;
Defaulter Tracing and Continuing Drug Replacement.

Outreach Services Home Visits

Growth Monitoring;
Nutrition Advisory Services and
Product Distribution;
School Health;
Immunization and Vaccination
Services.
FP Counseling and Methods Supply;
ARI in Children;
Care of <5 Children;
Care of Infants (7-28 days);
Defaulter Tracing and Continuing Drug Replacement;
Malaria Case Management.
CHPS implementation cycle: All steps to be taken with total community engagement.

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Figure 1 CHPS implementation cycle

Major preliminary tasks in establishing CHPS:
Step 1. Zone & Epidemiological Mapping
General description of Socio economic status including demographic profile, human development
the Community activities, transportation, water and sanitation, electricity or source of power
and light, recreation, main economic activities, general nature of their dwellings
and poverty level if known
Health status Skilled Maternal Child Top five Penta3 Specific endemic
indicators * attendance Mortality Mortality diseases coverage disease to the
community

Existing Health Distance from the most Distance from the most clustered population of the
Service Delivery remote household of community by road
Community by road
Hospital
Clinic/Maternity
Home
CHPS Compound
Pharmacy/chemical
seller
Human Resources Doctors Midwives Nurses/CHO CHWs Traditional Birth Attendants
 Opportunities
• The President’s 10% voluntary salary cut/contribution to support
CHPS
• President’s Desire to Assess Performance of DCEs’ Delivery on
CHPS
• Min. Local Government and Rural Development
– Decentralization processes revival within the Local Government
• Ghana Health Service
– Operational Policy and Implementation Guidelines Review
• Centre for Health and Social Services (CHeSS):
– Transforming CHPS into Universal Coverage for MCH services
• Stakeholders (practicing CHOs, District CHPS Coordinators involved in support
supervision and monitoring, Community Members) have identified and expressed
the types of services needed at the community level;
• Services with 100% consensus from respondent groups have been prioritized as
the core services most in need at the community level.
And Coming up! cf
 Open forum for
Reflection and Discussion
 o u
k Y
a n
Th