Margaret L. Schmitt

Lessons learned from scaling up a community-based health program in the Upper East Region of northern Ghana

The original CHPS model deployed nurses to the community and engaged local leaders, reducing child mortality and fertility substantially. Key scaling-up lessons: (1) place nurses in home districts but not home villages, (2) adapt uniquely to each district, (3) mobilize local resources, (4) develop a shared project vision, and (5) conduct “exchanges” so that staff who are initiating operations can observe the model working in another setting, pilot the approach locally, and expand based on lessons learned. The original CHPS model deployed nurses to the community and engaged local leaders, reducing child mortality and fertility substantially. Key scaling-up lessons: (1) place nurses in home districts but not home villages, (2) adapt uniquely to each district, (3) mobilize local resources, (4) develop a shared project vision, and (5) conduct “exchanges” so that staff who are initiating operations can observe the model working in another setting, pilot the approach locally, and expand based on lessons learned. ABSTRACT Ghanas Community-Based Health Planning and Service (CHPS) initiative is envisioned to be a national program to relocate primary health care services from subdistrict health centers to convenient community locations. The initiative was launched in 4 phases. First, it was piloted in 3 villages to develop appropriate strategies. Second, the approach was tested in a factorial trial, which showed that community-based care could reduce childhood mortality by half in only 3 years. Then, a replication experiment was launched to clarify appropriate activities for implementing the fourth and final phase—national scale up. This paper discusses CHPS progress in the Upper East Region (UER) of Ghana, where the pace of scale up has been much more rapid than in the other 9 regions of the country despite exceedingly challenging economic, ecological, and social circumstances. The UER employed 5 strategies that facilitated scale up: (1) nurse recruitment from their home districts to improve worker morale and cultural grounding, balanced with some social distance from the village community to ensure client confidentiality, particularly regarding family planning use; (2) prioritization of CHPS planning and continuous review in management meetings to make necessary modifications to the initiatives approach; (3) community engagement and advocacy to local politicians to mobilize resources for financing start-up costs; (4) a shared and consistent vision about CHPS among health administration leaders to ensure appropriate resources and commitment to the initiative; and (5) knowledge exchange visits between new and advanced CHPS implementers to facilitate learning and scale up within and between districts.

Does the design and implementation of proven innovations for delivering basic primary health care services in rural communities fit the urban setting: the case of Ghana’s Community-based Health Planning and Services (CHPS)

BackgroundRapid urban population growth is of global concern as it is accompanied with several new health challenges. The urban poor who reside in informal settlements are more vulnerable to these health challenges. Lack of formal government public health facilities for the provision of health care is also a common phenomenon among communities inhabited by the urban poor. To help ameliorate this situation, an innovative urban primary health system was introduced in urban Ghana, based on the milestones model developed with the rural Community-Based Health Planning and Services (CHPS) system. This paper provides an overview of innovative experiences adapted while addressing these urban health issues, including the process of deriving constructive lessons needed to inform discourse on the design and implementation of the sustainable Community-Based Health Planning and Services (CHPS) model as a response to urban health challenges in Southern Ghana.MethodsThis research was conducted during the six-month pilot of the urban CHPS programme in two selected areas acting as the intervention and control arms of the design. Daily routine data were collected based on milestones initially delineated for the rural CHPS model in the control communities whilst in the intervention communities, some modifications were made to the rural milestones.ResultsThe findings from the implementation activities revealed that many of the best practices derived from the rural CHPS experiment could not be transplanted to poor urban settlements due to the unique organizational structures and epidemiological characteristics found in the urban context. For example, constructing Community Health Compounds and residential facilities within zones, a central component to the rural CHPS strategy, proved inappropriate for the urban sector. Night and weekend home visit schedules were initiated to better accommodate urban residents and increase coverage. The breadth of the disease burden of the urban residents also requires a broader expertise and training of the CHOs.ConclusionsAccess to improved urban health services remains a challenge. However, current policy guidelines for the implementation of a primary health model based on rural experiences and experimental design requires careful review and modifications to meet the needs of the urban settings.

What is the scope for addressing menstrual hygiene management in complex humanitarian emergencies? A global review

Global attention on improving the integration of menstrual hygiene management (MHM) into humanitarian response is growing. However, there continues to be a lack of consensus on how best to approach MHM inclusion within response activities. This global review assessed the landscape of MHM practice, policy, and research within the field of humanitarian response. This included an analysis of the limited existing documentation and research on MHM in emergencies and global key informant interviews (n=29) conducted with humanitarian actors from relevant sectors (water, sanitation, and hygiene; women’s protection; child protection; health; education; non-food items; camp management). The findings indicate that despite a growing dialogue around MHM in emergencies, there remains a lack of clarity on the key components for a complete MHM response, the responsible sectoral actors to implement MHM activities, and the most effective interventions to adapt in emergency contexts, and insufficient guidance on monitoring ...

Understanding the menstrual hygiene management challenges facing displaced girls and women: findings from qualitative assessments in Myanmar and Lebanon

BackgroundThere is a significant gap in empirical evidence on the menstrual hygiene management (MHM) challenges faced by adolescent girls and women in emergency contexts, and on appropriate humanitarian response approaches to meet their needs in diverse emergency contexts. To begin filling the gap in the evidence, we conducted a study in two diverse contexts (Myanmar and Lebanon), exploring the MHM barriers facing girls and women, and the various relevant sectoral responses being conducted (e.g. water, sanitation and hygiene (WASH), Protection, Health, Education and Camp Management).MethodsTwo qualitative assessments were conducted: one in camps for internally displaced populations in Myanmar, and one with refugees living in informal settlements and host communities in Lebanon. Key informant interviews were conducted with emergency response staff in both sites, and focus group discussion and participatory mapping activities conducted with adolescent girls and women.ResultsKey findings included that there was insufficient access to safe and private facilities for MHM coupled with displacement induced shifts in menstrual practices by girls and women. Among staff, there was a narrow interpretation of what an MHM response includes, with a focus on supplies; significant interest in understanding what an improved MHM response would include and acknowledgement of limited existing MHM guidance across various sectors; and insufficient consultation with beneficiaries, related to discomfort asking about menstruation, and limited coordination between sectors.ConclusionsThere is a significant need for improved guidance across all relevant sectors for improving MHM response in emergency context, along with increased evidence on effective approaches for integrating MHM into existing responses.

Benefits and Limitations of a Community-Engaged Emergency Referral System in a Remote, Impoverished Setting of Northern Ghana

A low-cost emergency and communication transportation system used 3-wheeled motorcycles driven by trained community volunteers. Delivery referrals were redirected from health centers to hospitals capable of advanced services including cesarean deliveries, which was associated with reduced facility-based maternal mortality. A low-cost emergency and communication transportation system used 3-wheeled motorcycles driven by trained community volunteers. Delivery referrals were redirected from health centers to hospitals capable of advanced services including cesarean deliveries, which was associated with reduced facility-based maternal mortality. ABSTRACT Although Ghana has a well-organized primary health care system, it lacks policies and guidelines for developing or providing emergency referral services. In 2012, an emergency referral pilot—the Sustainable Emergency Referral Care (SERC) initiative—was launched by the Ghana Health Service in collaboration with community stakeholders and health workers in one subdistrict of the Upper East Region where approximately 20,000 people reside. The pilot program was scaled up in 2013 to a 3-district (12-subdistrict) plausibility trial that served a population of approximately 184,000 over 2 years from 2013 to 2015. The SERC initiative was fielded as a component of a 6-year health systems strengthening and capacity-building project known as the Ghana Essential Health Intervention Program. Implementation research using mixed methods, including quantitative analysis of key process and health indicators over time in the 12 intervention subdistricts compared with comparison districts, a survey of health workers, and qualitative systems appraisal with community members, provided data on effectiveness of the system as well as operational challenges and potential solutions. Monitoring data show that community exposure to SERC was associated with an increased volume of emergency referrals, diminished reliance on primary care facilities not staffed or equipped to provide surgical care, and increased caseloads at facilities capable of providing appropriate acute care (i.e., district hospitals). Community members strongly endorsed the program and expressed appreciation for the service. Low rates of adherence to some care protocols were noted: referring facilities often failed to alert receiving facilities of incoming patients, not all patients transported were accompanied by a health worker, and receiving facilities commonly failed to provide patient outcome feedback to the referring facility. Yet in areas where SERC worked to bypass substandard points of care, overall facility-based maternal mortality as well as accident-related deaths decreased relative to levels observed in facilities located in comparison areas.

A qualitative appraisal of stakeholder reactions to a tool for burden of disease–based health system budgeting in Ghana

Background In 2010, the Ghana Health Service launched a program of cooperation with the Tanzania Ministry of Health and Social Welfare that was designed to adapt Tanzanias PLANREP budgeting and reporting tool to Ghanas primary health care program. The product of this collaboration is a system of budgeting, data visualization, and reporting that is known as the District Health Planning and Reporting Tool (DiHPART). Objective This study was conducted to evaluate the design and implementation processes (technical, procedures, feedback, maintenance, and monitoring) of the DiHPART tool in northern Ghana. Design This paper reports on a qualitative appraisal of user reactions to the DiHPART system and implications of pilot experience for national scale-up. A total of 20 health officials responsible for financial planning operations were drawn from the national, regional, and district levels of the health system and interviewed in open-ended discussions about their reactions to DiHPART and suggestions for systems development. Results The findings show that technical shortcomings merit correction before scale-up can proceed. The review makes note of features of the software system that could be developed, based on experience gained from the pilot. Changes in the national system of financial reporting and budgeting complicate DiHPART utilization. This attests to the importance of pursuing a software application framework that anticipates the need for automated software generation. Conclusions Despite challenges encountered in the pilot, the results lend support to the notion that evidence-based budgeting merits development and implementation in Ghana.Background In 2010, the Ghana Health Service launched a program of cooperation with the Tanzania Ministry of Health and Social Welfare that was designed to adapt Tanzanias PLANREP budgeting and reporting tool to Ghanas primary health care program. The product of this collaboration is a system of budgeting, data visualization, and reporting that is known as the District Health Planning and Reporting Tool (DiHPART). Objective This study was conducted to evaluate the design and implementation processes (technical, procedures, feedback, maintenance, and monitoring) of the DiHPART tool in northern Ghana. Design This paper reports on a qualitative appraisal of user reactions to the DiHPART system and implications of pilot experience for national scale-up. A total of 20 health officials responsible for financial planning operations were drawn from the national, regional, and district levels of the health system and interviewed in open-ended discussions about their reactions to DiHPART and suggestions for systems development. Results The findings show that technical shortcomings merit correction before scale-up can proceed. The review makes note of features of the software system that could be developed, based on experience gained from the pilot. Changes in the national system of financial reporting and budgeting complicate DiHPART utilization. This attests to the importance of pursuing a software application framework that anticipates the need for automated software generation. Conclusions Despite challenges encountered in the pilot, the results lend support to the notion that evidence-based budgeting merits development and implementation in Ghana.Background In 2010, the Ghana Health Service launched a program of cooperation with the Tanzania Ministry of Health and Social Welfare that was designed to adapt Tanzanias PLANREP budgeting and reporting tool to Ghanas primary health care program. The product of this collaboration is a system of budgeting, data visualization, and reporting that is known as the District Health Planning and Reporting Tool (DiHPART). Objective This study was conducted to evaluate the design and implementation processes (technical, procedures, feedback, maintenance, and monitoring) of the DiHPART tool in northern Ghana. Design This paper reports on a qualitative appraisal of user reactions to the DiHPART system and implications of pilot experience for national scale-up. A total of 20 health officials responsible for financial planning operations were drawn from the national, regional, and district levels of the health system and interviewed in open-ended discussions about their reactions to DiHPART and suggestions for systems development. Results The findings show that technical shortcomings merit correction before scale-up can proceed. The review makes note of features of the software system that could be developed, based on experience gained from the pilot. Changes in the national system of financial reporting and budgeting complicate DiHPART utilization. This attests to the importance of pursuing a software application framework that anticipates the need for automated software generation. Conclusions Despite challenges encountered in the pilot, the results lend support to the notion that evidence-based budgeting merits development and implementation in Ghana.

Estimating indices of health system readiness: an example from rural northern Ghana

Abstract Background There is growing recognition that stronger health systems are necessary to accelerate progress towards the Millennium Development Goals (MDGs). However, a departure from disease-specific programmes and interventions requires the development of a new empirical framework for programme evaluation that focuses on indicators of health system strengthening. Service provision assessment (SPA) surveys provide a wealth of data about health system resources, but they often include too many indicators to provide useful insight into general systems strength or service readiness. To improve the usefulness of such data, we have applied multidimensional statistical data reduction techniques to SPA data with the aim of developing robust measures of health system capabilities. Methods Data for the construction of indices were derived from the 2010 Ghana Emergency Obstetric and Newborn Care (EmONC) survey published by the Ghanaian Ministry of Health. This survey included a saturated sample of 147 health facilities in the Upper East Region. The instrument assessed facility readiness and performance using 3872 service and outcome indicators of: infrastructure; human resources; availability of drugs, equipment, and supplies; and knowledge of essential procedures. Of those indicators, 872 were identified as corresponding to one of the six WHO health system building blocks. Dimensionality reduction was done using principal component analysis. Where appropriate, we reorganised binary indicators into ordinal categorical variables, as is commonly done in the socioeconomic status literature. We also assessed the external validity of the new index. Findings Results from the principal component analysis of the 872 health systems indicators suggest that a single component (PC1) explains more than 30% of the common variance among the health facilities surveyed. An index composed of the factor loadings from PC1 showed marked variation between facilities (SD 13·077) with easily identifiable clusters of facility type (hospital, health centre, clinic, community compound). The distribution of PC1 also suggested concentration of resources among a few high-level facilities (Gini 0·508). Compared with EmONC signal functions, the index scores were better predictors of the number of deliveries (R 2 0·61 vs R 2 0·31) and the number of low birthweight babies (0·68 vs 0·26) as well as maternal deaths (0·81 vs 0·34) and neonatal deaths (0·79 vs 0·36). Interpretation Our findings suggest that an index of health system readiness that captures a large portion of facility variance can be constructed from SPA data using principal component analysis. In practice, such an index could be used to monitor progress towards stronger health systems. However, further research is needed to determine how an increase in index score which is input-focused, affects population health. Particular attention must also be paid to the performance determinants that maximise the efficient use of health system inputs. Funding Support for this study was provided by the African Health Initiative with funding from the Doris Duke Charitable Foundation.