PROMOTING HEALTH SYSTEMS RESILIENCE IN THE FRAGILE CONTEXT OF NORTHERN GHANA: A STUDY OF COMMUNITY-BASED HEALTH PLANNING AND SERVICES (CHPS) EFFECTIVENESS

In 1999, the government of Ghana adopted the Community-based Health Planning and Services (CHPS) programme as a national policy. It then launched a scaling-up initiative in 2000 to support its Universal Health Care (UHC) agenda. Since its adoption, CHPS has significantly contributed to health service delivery in Ghana, such as improved family planning and immunization coverage. Despite these gains, however, critical implementation gaps persist. Doorstep services and volunteer support, necessary for supporting population health and family planning in marginalised communities, continue to diminish and CHPS scale-up in fragile settings such as the Northern region of Ghana, where poverty is high and health indicators relatively low, is slow. This research investigated the factors constraining the implementation and effectiveness of CHPS in the fragile context of the Northern region of Ghana using a mixed-methods research methodology. Data collection was completed in three distinct stages, comprising 1) a review of the district health information management system (DHIMS) data; 2) key informant interviews and focus group discussions (FGDs) with CHPS stakeholders at the national, regional, district, sub-district, CHPS and community levels; and 3) participatory research using group model building (GMB) in the Kumbungu and Gushiegu districts of the former Northern region. Findings identify that the Ghanaian Government is the main contributor to CHPS infrastructure. However, nearly all participating district facilities were ill-equipped and did not have adequate equipment and medicines owing to lapses in central government funding and National Health Insurance Scheme (NHIS) reimbursement challenges. As a result, there was a general perception of neglect among community members. The participatory research findings conclude that CHPS implementation was confronted by inadequate funding to support the programme’s implementation, poor community engagement and support, and diminished health worker capacity owing to gaps in training, logistics, equipment, and infrastructure. These are further compounded by the drivers of fragility resulting from high poverty levels and a vicious cycle of debt servicing. To mitigate the identified barriers, stakeholders during the study developed a set of interventions aimed at improving CHPS effectiveness. Feedback interviews twelve months after the GMBs showed good progress for interventions targeting health worker capacity, logistics management and community engagement. Comparatively, there was more progress for community engagement interventions than interventions relating to increasing political commitment and funding. Beyond identifying the enablers for CHPS effectiveness, this study supports the argument that the concept of fragility reaches beyond situations of conflict and disasters to include systemic challenges, such as the failure of governments to provide adequate resources to foster the smooth delivery of basic health services. This is particularly so in the context of this research where funding for health services is mainly centralised in a decentralised country. Comparatively, the community engagement interventions had more progress than the interventions for increasing political commitment and funding. In poor and marginalised settings, effective and sustained community engagement can bridge resource gaps, empower users to demand accountability from officials and contribute to resilient health systems. Using the GMB systems thinking methodology presented a holistic approach to understanding the systemic barriers to CHPS implementation and identified enablers that can minimise their impact on the programme. This approach of bringing together community members, health workers and policymakers on a shared platform was particularly appreciated by community members who seldom share a common platform with government officials in matters of social discourse

Scaling up Access to Misoprostol at the Community Level to Improve Maternal Health Outcomes in Ethiopia, Ghana, and Nigeria

Over the past decade (2004–2014), the Population and Reproductive Health area of the MacArthur Foundation has focused on supporting projects aimed at reducing maternal mortality. In particular, it has supported efforts to use misoprostol to prevent postpartum hemorrhage, the anti-shock garment to aid in the treatment of hemorrhage, and magnesium sulfate to decrease deaths from eclampsia. In recent years, the Foundation has invested in a range of research and evaluation efforts to better understand these interventions, their effectiveness, and the extent to which successful pilot projects have been scaled up.In 2014, the Foundation commissioned the Public Health Institute to evaluate the grants it had made to increase community-based access to misoprostol for postpartum hemorrhage prevention in Ethiopia, Ghana, and Nigeria. Specifically, the Foundation was interested in documenting the models and approaches used and the progress toward scaling up the respective models in the three countries. Between June and November 2014, the evaluation team reviewed grantee reports, proposals, and the literature; interviewed key informants and global, national, and local stakeholders; conducted focus group discussions with local stakeholders; and made observations during site-visits in each country. From this the team produced case study reports relating to misoprostol use in each country. This report is a synthesis of those three case studies, highlighting the common findings across the projects, identifying differences, and interpreting the lessons learned for broader use and scale up of misoprostol at the community level in Africa and globally

Understanding fragility: Implications for global health research and practice

Karin Diaconu - ORCID 0000-0002-5810-9725 https://orcid.org/0000-0002-5810-9725Sophie Witter - ORCID 0000-0002-7656-6188 https://orcid.org/0000-0002-7656-6188Advances in population health outcomes risk being slowed—and potentially reversed—by a range of threats increasingly presented as ‘fragility’. Widely used and critiqued within the development arena, the concept is increasingly used in the field of global health, where its relationship to population health, health service delivery, access and utilization is poorly specified. We present the first scoping review seeking to clarify the meaning, definitions and applications of the term in the global health literature. Adopting the theoretical framework of concept analysis, 10 bibliographic and grey literature sources, and five key journals, were searched to retrieve documents relating to fragility and health. Reviewers screened titles and abstracts and retained documents applying the term fragility in relation to health systems, services, health outcomes and population or community health. Data were extracted according to the protocol; all documents underwent bibliometric analysis. Narrative synthesis was then used to identify defining attributes of the concept in the field of global health. A total of 377 documents met inclusion criteria. There has been an exponential increase in applications of the concept in published literature over the last 10 years. Formal definitions of the term continue to be focused on the characteristics of ‘fragile and conflict-affected states’. However, synthesis indicates diverse use of the concept with respect to: level of application (e.g. from state to local community); emphasis on particular antecedent stressors (including factors beyond conflict and weak governance); and focus on health system or community resources (with an increasing tendency to focus on the interface between two). Amongst several themes identified, trust is noted as a key locus of fragility at this interface, with critical implications for health seeking, service utilization and health system and community resilience.This research was funded by the National Institute for Health Research (NIHR) Global Health Research Programme 16/136/100. The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR or the Department of Health.https://doi.org/10.1093/heapol/czz14235pubpub

Supporting the utilization of community-based primary health care implementation research in Ghana

From Crossref journal articles via Jisc Publications RouterItem not available in this repository.Ever since the 1990s, implementation research in Ghana has guided the development of policies and practices that are essential to establishing community-based primary health care. In response to evidence emerging from this research, the Community-based Health Planning and Services (CHPS) policy was promulgated in 1999 to scale-up results. However, during the first decade of CHPS operation, national monitoring showed that its pace of coverage expansion was unacceptably slow. In 2010, the Ghana Health Service launched a five-year plausibility trial of CHPS reform for testing ways to accelerate scale-up. This initiative, known as the Ghana Essential Health Intervention Program (GEHIP), included a knowledge management component for establishing congruence of knowledge generation and flow with the operational system that GEHIP evidence was intended to reform. Four Upper East Region districts served as trial areas while seven districts were comparison areas. Interventions tested means of developing the upward flow of information based on perspectives of district managers, sub-district supervisors, and community-level workers. GEHIP also endeavored to improve procedures for the downward flow and utilization of policy guidelines. Field exchanges were convened for providing national, regional, and district leaders with opportunities for participatory learning about GEHIP implementation innovations. This systems approach facilitated the process of augmenting the communication of evidence with practical field experience. Scientific rigor associated with the production of evidence was thereby integrated into management decision-making processes in ways that institutionalized learning at all levels. The GEHIP knowledge management system functioned as a prototype for guiding the planning of a national knowledge management strategy. A follow-up project transferred its mechanisms from the Upper East Regional Health Administration to the Policy Planning Monitoring and Evaluation Division of the Ghana Health Service in Accra.Funder: Doris Duke Charitable Foundation; FundRef: 10.13039/100000862; Grant(s): 201610737pubpub