Implementation research for integrated health system strengthening in Ghana : towards tipping point for improved health systems performance and population health

Recent decades have witnessed the proliferation of large-scale initiatives for improving health systems. Strategies such as the Bamako Initiative, the Sector-Wide Approach, Child Survival+ and many others were instituted with compelling rationales for improving the provision of essential health services. Yet, large-scale investments in untested health system initiatives have often been associated with disappointing results, or with little formal evidence that investments in organizational strategies have actually improved health. Interestingly, no prior study has tested the proposition that the six WHO health system building block subsystems (integrated health service delivery, health workforce, information for decision making, essential drug supplies and logistics, health financing and resources allocation and leadership and governance) can be strengthened with an integrated package of systems interventions in ways that can accelerate the pace of improvements in child health and survival. If such incremental effects can be demonstrated, prospects for expanding international and national commitment to health systems strengthening will be greatly enhanced and specific lessons from implementation research and operational experience of this nature will be invaluable to health planners. Health services delivery in Ghana is decentralized and in discharging its constitutional mandate to expand access to healthcare, the Government of Ghana has implemented policies that mandate a system of services, referral operations and supervisory roles for health care services that is provided in hospitals, sub-district health centres and community-based facilities. Health service innovations are provided at the community level through a policy known as the Community-based Health Planning and Services (CHPS) Initiative that aims to mobilize community leadership, decision-making systems and resources in poor rural areas; relocate facility-based nurses to community service points called “CHPS zones” and orient these workers to the active provision of community-based outreach and doorstep healthcare. CHPS also supports nurses with logistics and community volunteer systems to provide services according to the principles of primary healthcare including integrated management of childhood illnesses, comprehensive immunization services and basic safe motherhood care. Despite efforts to implement this community-based health system, a number of challenges have emerged that limit access to service delivery using the six WHO health systems building block subsystems. Critically identified are the following challenges: 1. Governance: Leadership and governance systems are poorly understood and inadequately marshalled for health development at the local and community level. 2. Financing: Budgets and financial plans are largely determined by past budgets or external vertical programmes rather than resource allocation that is based on the configuration of need. 3. Information: Health information capability to support decentralized healthcare system has instead been a time consuming data extraction process for the health insurance and central health bureaucracy rather than a system for community-based healthcare workers that contributes to their work, decision-making, or supervisory support needs. 4. Logistics: Even though there is deemed to be a decentralized management of health services, there is still a centralized medical stores system, resulting in episodes of catastrophic breakdown in supply chains, with stock-outs that are exacerbated when district health service operations increase. 5. Human resources: Shortages in the district health management, midwifery, and nursing workforce arise, either because of their inappropriate posting location or inadequate numbers as well as poor leadership that seriously undermines efforts to strengthen the health systems. This work reviews the Ghana Essential Health Interventions Project (GEHIP), implemented in the Upper East Region of Ghana to contribute to the health systems strengthening policy by testing the health and survival impact of strengthening the primary health care system. GEHIP tested the hypothesis that integrated system initiatives cutting across the WHO “pillars” of health system strengthening can improve system performance to the point of having an impact on population and health outcomes and ensure that essential health interventions reach under-served populations and progress towards Millennium Development Goal (MDG) 4 can be achieved. The project essentially focused on strengthening district-level capacity to plan and set priorities using locally obtained burden of disease and cost-effectiveness data in order to increase the effectiveness of Ghana’s Community-based Health Planning and Services (CHPS) programme, with the goal of accelerating the expansion of CHPS coverage and improving the quality of CHPS provided care. A mixed methodology was used to gauge the impact of the health system functioning according to a framework of interventions spanning the six WHO health systems building block subsystems. Aggregate impact of GEHIP on child survival was tested with the Heckman “difference of differences” procedure using results from a baseline survey that was conducted in 2010 and an endline survey conducted in 2015 in four treatment and seven comparison districts. Qualitative Systems Appraisal (QSA) in the form of in-depth interviews and focus group investigations of community stakeholders, frontline workers, supervisors, and district health managers was employed to gauge reactions to the GEHIP system, clarify inputs by the health subsystem, reactions to these inputs and recommendations for systems change. Regression methods were used to refine the Heckman procedure, adjusting for potential confounders and estimating net effects of household exposure to GEHIP improved care on the survival of children. GEHIP is a quasi-experimental study of a project designed to accelerate the scale up of one of the most effective health development experiments ever conducted in Africa –The “Navrongo Experiment”. It supplements the provision of effective primary healthcare strategies with leadership training, field demonstration, improved budgeting and resource mobilization. By means of these interventions, GEHIP sought to enhance health equity, mitigate social and monetary health care costs, foster parental health seeking behaviour and improve maternal and child survival. Training was designed to expand access to life saving technology that reduces neonatal, infant, and childhood mortality. Additional components for improving referral, neonatal survival, and maternal health rekindled Ghana’s legacy of generating evidence-based means of achieving affordable and accessible primary health care throughout Ghana. Findings from this work have shown that the combined effects of leadership training, catalytic investment, political engagement, and evidence-based budgeting are capable of solving CHPS start-up problem and accelerate scale up. At baseline, neonatal and maternal mortality rates were unacceptably high, but the rapid training of frontline workers proved to be inexpensive, operationally feasible, and potentially effective in reducing maternal and neonatal mortality. Moreover, an innovative pilot referral system utilizing locally appropriate tri-car ambulances has been implemented and information systems have been reformed through the adoption of a simplified register system with impressive results. Accelerating CHPS scale-up is crucial to health development in Ghana where the expansion of CHPS has languished because district health systems strengthening requirements were unanticipated by national policies. Research results showed that the interventions had their intended impact on the pace of CHPS scale-up. This success translated into an impact on child mortality resulting in GEHIP providing a critically needed focus for national efforts to develop primary health care, and lessons for global healt

Evaluation of the reporting completeness and timeliness of the integrated disease surveillance and response system in northern Ghana

Objectives: The integrated disease surveillance and response (IDSR) and district health information management system II (DHIMS2) strategies were implemented in 2002 and 2012 respectively to improve surveillance data reporting and quality. The objective of this study was to evaluate the reporting completeness and timeliness of the IDSR system at the sub-national level in northern Ghana.Methods: This was an observational study in Upper East Region (UER). Weekly and monthly disease surveillance reports on completeness and timeliness were downloaded and analysed for 2012 and 2013 from the DHIMS2 in UER, the two Kassena-Nankana districts and their nine health facilities representing public, private and mission providers. Comparison of paper-based and DHIMS2 reporting from the periphery health facilities were assessed.Results: IDSR monthly reporting completeness and timeliness in UER increased by 9% and 37% respectively in 2013 compared to 2012 and weekly completeness and timeliness improved by 79% and 24% respectively in 2013. Similar reporting increases were seen in the districts and health facilities over the same period, except the Kassena-Nankana Municipal which showed decrease of 2% in monthly completeness for 2013. At the health facilities, the paper-based reporting completeness was 96% and timeliness 45% while DHIMS2 completeness was 83% and timeliness 18% in 2012. However, DHIMS2 reporting completeness and timeliness improved in 2013 reaching 100% and 61% respectively.Conclusions: Disease surveillance reporting through DHIMS2 became more complete over time, but there remain problems with timeliness. Surveillance data need to be timely to enable rapid responses to disease outbreaks.Keywords: disease surveillance, completeness, timeliness, health information system, Ghan

Translating research findings into practice – the implementation of kangaroo mother care in Ghana

BACKGROUND: Kangaroo mother care (KMC) is a safe and effective method of caring for low birth weight infants and is promoted for its potential to improve newborn survival. Many countries find it difficult to take KMC to scale in healthcare facilities providing newborn care. KMC Ghana was an initiative to scale up KMC in four regions in Ghana. Research findings from two outreach trials in South Africa informed the design of the initiative. Two key points of departure were to equip healthcare facilities that conduct deliveries with the necessary skills for KMC practice and to single out KMC for special attention instead of embedding it in other newborn care initiatives. This paper describes the contextualisation and practical application of previous research findings and the results of monitoring the progress of the implementation of KMC in Ghana. METHODS: A three-phase outreach intervention was adapted from previous research findings to suit the local setting. A more structured system of KMC regional steering committees was introduced to drive the process and take the initiative forward. During Phase I, health workers in regions and districts were oriented in KMC and received basic support for the management of the outreach. Phase II entailed the strengthening of the regional steering committees. Phase III comprised a more formal assessment, utilising a previously validated KMC progress-monitoring instrument. RESULTS: Twenty-six out of 38 hospitals (68 %) scored over 10 out of 30 and had reached the level of ‘evidence of practice’ by the end of Phase III. Seven hospitals exceeded expected performance by scoring at the level of ‘evidence of routine and institutionalised practice.’ The collective mean score for all participating hospitals was 12.07. Hospitals that had attained baby-friendly status or had been re-accredited in the five years before the intervention scored significantly better than the rest, with a mean score of 14.64. CONCLUSION: The KMC Ghana initiative demonstrated how research findings regarding successful outreach for the implementation of KMC could be transferred to a different context by making context-appropriate adaptations to the model.The United Nations Children’s Fundhttp://www.implementationscience.com/content/7/1/7

Community perceptions of universal health coverage in eight districts of the Northern and Volta regions of Ghana

Background: Ever since Ghana embraced the 1978 Alma-Ata Declaration, it has consigned priority to achieving ‘Health for All.’ The Community-based Health Planning and Services (CHPS) Initiative was established to close gaps in geographic access to services and health equity. CHPS is Ghana’s flagship Universal Health Coverage (UHC) Initiative and will soon completely cover the country with community-located services. Objectives: This paper aims to identify community perceptions of gaps in CHPS maternal and child health services that detract from its UHC goals and to elicit advice on how the contribution of CHPS to UHC can be improved. Method: Three dimensions of access to CHPS care were investigated: geographic, social, and financial. Focus group data were collected in 40 sessions conducted in eight communities located in two districts each of the Northern and Volta Regions. Groups were comprised of 327 participants representing four types of potential clientele: mothers and fathers of children under 5, young men and young women ages 15–24. Results: Posting trained primary health-care nurses to community locations as a means of improving primary health-care access is emphatically supported by focus group participants, even in localities where CHPS is not yet functioning. Despite this consensus, comments on CHPS activities suggest that CHPS services are often compromised by cultural, financial, and familial constraints to women’s health-seeking autonomy and by programmatic lapses constrain implementation of key components of care. Respondents seek improvements in the quality of care, community engagement activities, expansion of the range of services to include emergency referral services, and enhancement of clinical health insurance coverage to include preventive health services. Conclusion: Improving geographic and financial access to CHPS facilities is essential to UHC, but responding to community need for improved outreach, and service quality is equivalently critical to achieving this goal