Community-Based Health Planning and Services (CHPS) concept and access to healthcare delivery in Sefwi Wiawso Municipal, Ghana.

BACKGROUND: In spite of the successes of the community-based health planning and services (CHPS) policy since its inception in the mid-1990s in Ghana, data pertaining to the implementation and use of CHPS facilities in Sefwi Wiawso Municipal is scant. We assessed access to healthcare delivery and factors influencing the use of CHPS in Sefwi Wiawso Municipal. METHODS: An analytical community-based cross-sectional study was conducted in the Sefwi Wiawo Municipal from September to October 2020. Respondents for the study were recruited through multi-stage sampling. Information was collected on their socio-demographic characteristics, knowledge and use of CHPS facilities through interviews using a structured pre-tested questionnaire. Factors influencing the use of CHPS facilities were assessed using univariable and multivariable logistic regression to generate crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs). P ≤ 0.05 was considered statistically significant. RESULTS: A total of 483 respondents were recruited for the study. The mean age of the respondents was 43.0 ± 16.3 years, and over 70% were females or married/cohabiting with their partners. Most respondents (88.2%) knew about the CHPS concept and more than half (53.4%) accessed healthcare in the CHPS facilities. Most respondents rated the quality of health services (> 65%) and staff attitude (77.2%) very positively. Significant factors influencing the use of the CHPS facilities were; knowledge of the CHPS concept (AOR 6.57, 95% CI 1.57-27.43; p = 0.01), longer waiting time for a vehicle to the facility, and shorter waiting time at the facility before being provided with care. People who waited for 30-60 min (AOR 2.76, 95% CI 1.08-7.07; p = 0.01) or over an hour (AOR 10.91, 95% CI 3.71-32.06; p = 0.01) before getting a vehicle to the facility, while patients who waited for less than 30 min (AOR 5.74, 95% CI 1.28-25.67; p = 0.03) or 30-60 min (AOR 2.60, 95% CI 0.57-11.78; p = 0.03) at the CHPS facility before receiving care were more likely to access care at the CHPS facilities. CONCLUSION: Knowledge, and use of healthcare services at the CHPS facilities were high in this population. Interventions aimed at reducing waiting time at the CHPS facilities could greatly increase use of healthcare services at these facilities.

Impact of community health interventions on maternal and child health indicators in the upper east region of Ghana.

BACKGROUND: This paper reports on results of a health system strengthening implementation research initiative conducted the Upper East Region of northern Ghana. Transformative interventions to accelerate and strengthen the health delivery were implemented that included empowering community leaders and members to actively participate in health delivery, strengthening the referral systems through the provision of community transport systems, providing basic medical equipment to community clinics, and improving the skills of critical health staff through training. METHODS: A mixed method design was used to evaluate the impact of the interventions. A quantitative evaluation employed a flexible research design to test the effects of various component activities of the project. To assess impact, a pre-versus-post randomized cluster survey design was used. Qualitative research was conducted with focus group data and individual in depth interviews to gauge the views of various stakeholders associated with the implementation process. RESULTS: After intervention, significant improvements in key maternal and child health indicators such as antenatal and postnatal care coverage were observed and increases in the proportion of deliveries occurring in health facilities and assisted by skilled health personnel relative to pre-intervention conditions. There was also increased uptake of oral rehydration salts (ORS) for treatment of childhood diarrhoea, as well as marked reductions in the incidence of upper respiratory infections (URI). CONCLUSIONS: A pre-and post-evaluation of impact suggests that the programme had a strong positive impact on the functioning of primary health care. Findings are consistent with the proposition that the coverage and content of the Ghana Community-based Health Planning and Services programme was improved by program interventions and induced discernable changes in key indicators of health system performance.

Utilization of the national cluster of district health information system for health service decision-making at the district, sub-district and community levels in selected districts of the Brong Ahafo region in Ghana.

BACKGROUND: There is growing interest in the use of reliable evidence for health decision-making among low-and middle-income countries. Ghana has deployed DHIMS2 to replace the previously existing manual data harmonization processes. METHODS: This cross-sectional study was conducted in 12 districts comprising 12 district directorates, 10 district hospitals, 29 sub-district health centers, and 38 community health facilities in the Brong-Ahafo Region. Data collection tools were developed based on the Measure Evaluate assessment tools designed for evaluating the performance of routine information systems management tools. Utilization was assessed based on documented evidence and data was analyzed using STATA version 14. RESULTS: Although 93% of the health facilities studied submitted data unto the DHIMS2 platform, evidence suggested low use of this data in decision-making, particularly at the community level facilities where only 26% of the facilities used data from DHIMS2 to inform annual action plans and even less than 20% examined findings and issued directives for action. At the district level, 58% issued directives based on DHIMS2 information, 50% used DHIMS2 information for Advocacy purposes and 58% gave feedback reports based on DHIMS2 data for action. Functional computers were lacking across all facilities. CONCLUSIONS: Activities relating to the use of DHIMS2 information skew towards data quality checking with less focus on examining findings, making comparisons, and taking action-based decisions from findings and comparisons. Improving factors like internet access, availability of functional ICTs, frequency of supervisory visits, staff training and the provision of training manuals may facilitate the use of DHIMS2 in decision-making at all levels of the district health system.

Community utilisation and satisfaction with the community-based health planning and services initiative in Ghana: a comparative study in two system learning districts of the CHPS+ project.

BACKGROUND: To strengthen the implementation of the Community-based Health Planning and Services (CHPS) programme which is Ghana's key primary health care delivery strategy, the CHPS+ Project was initiated in 2017. We examined community utilisation and satisfaction with CHPS services in two System Learning Districts (SLDs) of the project. METHODS: This community-based descriptive study was conducted in the Nkwanta South Municipality and Central Tongu District of Ghana. Data were collected from 1008 adults and analysed using frequency, percentage, chi-square, and logistic regression models. RESULTS: While the level of utilisation of CHPS services was 65.2%, satisfaction was 46.1%. Utilisation was 76.7% in Nkwanta South and 53.8% in Central Tongu. Satisfaction was also 55.2% in Nkwanta South and 37.1% in Central Tongu. Community members in Nkwanta South were more likely to utilise (AOR = 3.17, 95%CI = 3.98-9.76) and be satisfied (AOR = 2.77, 95%CI = 1.56-4.90) with CHPS services than those in Central Tongu. Females were more likely to utilise (AOR = 1.75, 95%CI = 1.27-2.39) but less likely to be satisfied [AOR = 0.47, 95%CI = 0.25-0.90] with CHPS services than males. Even though subscription to the National Health Insurance Scheme (NHIS) was just 46.3%, NHIS subscribers were more likely to utilise (AOR = 1.51, 95%CI = 1.22-2.03) and be satisfied (AOR = 1.45, 95%CI = 0.53-1.68) with CHPS services than non-subscribers. CONCLUSION: Ghana may not be able to achieve the goal of universal health coverage (UHC) by the year 2030 if current levels of utilisation and satisfaction with CHPS services persist. To accelerate progress towards the achievement of UHC with CHPS as the vehicle through which primary health care is delivered, there should be increased public education by the Ghana Health Service (GHS) on the CHPS concept to increase utilisation. Service quality should also be improved by the GHS and other stakeholders in Ghana's health industry to increase satisfaction with CHPS services. The GHS and the National Health Insurance Authority (NHIA) should also institute innovative strategies to increase subscription to the NHIS since it has implications for CHPS service utilisation and satisfaction.

The influence of the Community-based Health Planning and Services (CHPS) program on community health sustainability in the Upper West Region of Ghana.

Ghana introduced Community-based Health Planning and Services (CHPS) to improve primary health care in rural areas. The extension of health care services to rural areas has the potential to increase sustainability of community health. Drawing on the capitals framework, this study aims to understand the contribution of CHPS to the sustainability of community health in the Upper West Region of Ghana-the poorest region in the country. We conducted in-depth interviews with community members (n = 25), key informant interviews with health officials (n = 8), and focus group discussions (n = 12: made up of six to eight participants per group) in six communities from two districts. Findings show that through their mandate of primary health care provision, CHPS contributed directly to improvement in community health (eg, access to family planning services) and indirectly through strengthening social, human, and economic capital and thereby improving social cohesion, awareness of health care needs, and willingness to take action at the community level. Despite the current contributions of CHPS in improving the sustainability of community health, there are several challenges, based on which we recommend, that government should increase staffing and infrastructure in order to strengthen and maintain the functionality of CHPS.

The hypolipidemic effects of peptides prepared from Cicer arietinum in ovariectomized rats and HepG2 cells.

BACKGROUND: The lack of estrogen in postmenopausal women is a key risk factor for disorders of lipid metabolism and for obesity. Except in cases where estrogen replacement therapy (ERT) is being used, chickpea peptides (ChPs) may be a potential candidate for treating hyperlipidemia. RESULTS: In ovariectomized rats model, ChPs were found to decrease body weight, adipose tissue size, total cholesterol (TC), total triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), and the atherogenic index (AI) in serum and liver TC and TG. Serum high-density lipoprotein cholesterol (HDL-C), bile acids in liver and feces, fecal TC and TG were observed to increase significantly (P < 0.05). ChPs play a role in inhibiting the activities of fatty acid synthetase (FAS) and HMG-CoA reductase (HMGR). The expression of peroxisome proliferator-activated receptors (PPAR)γ and sterol regulatory element-binding protein (SREBP)-1c were downregulated and the expression of liver X receptor (LXR) α, estrogen receptor(ER)α and ERß were upregulated by ChPs. In HepG2 cell experiments, the cellular TC levels decreased and the uptake of NBD-cholesterol increased significantly after treatment with Mw < 1 kDa and Mw < 5 kDa ChPs fractions. Val-Phe-Val-Arg-Asn (VFVRN) could inhibit TC biosynthesis by decreasing the expression of HMGR. CONCLUSION: We demonstrated that ChPs could effectively regulate lipid metabolism disorders and restrain obesity caused by estrogen deficiency. Val-Phe-Val-Arg-Asn identified from ChPs could reduce the expression of HMGR to inhibit cholesterol biosynthesis. © 2018 Society of Chemical Industry.

Universal health coverage necessitates a system approach: an analysis of Community-based Health Planning and Services (CHPS) initiative in Ghana.

The 9th Global conference on health promotion (Shanghai 2016) reaffirmed the role of primary health care (PHC) in achieving the 2030 Sustainable Development Agenda. Gaining much international recognition, the community-based health planning and services (CHPS) initiative is considered one of the pragmatic strategy in delivering on the promise of universal health coverage (UHC) through the PHC strategy, in Ghana. Yet, certain key factors threaten its successes - renewing the relevance of this study to present the barriers to and facilitators of the initiative. According to our findings, CHPS contribution particularly in bridging geographical access to health cannot be demeaned. Nevertheless, the full functioning of the initiative is limited by factors centered on the following themes: health governance and leadership, provision of services of quality, financial risk protection strategies targeting public health, information and care continuity, and the right mix of trained health professionals of even distribution across communities. Addressing the challenges of CHPS demand a system-approach. Substantial progress is more likely to emerge with improved leadership especially on the part of Governments to take bold political step to provide adequate financial and material resources. However, much will be achieved when stakeholders including the community work in synergies, to manage competing priorities by focusing on the core values and goals of CHPS.

Implementing Community-based Health Planning and Services in impoverished urban communities: health workers' perspective.

BACKGROUND: Three-quarters of sub-Saharan Africa's urban population currently live under slum conditions making them susceptible to ill health and diseases. Ghana characterizes the situation in many developing countries where the urban poor have become a group much afflicted by complex health problems associated with their living conditions, and the intra-city inequity between them and the more privileged urban dwellers with respect to health care accessibility. Adopting Ghana's rural Community-Based Health Planning and Service (CHPS) programme in urban areas is challenging due to the differences in social networks and health challenges thus making modifications necessary. The Community Health Officers (CHOs) and their supervisors are the frontline providers of health in the community and there is a need to analyze and document the health sector response to urban CHPS. METHODS: The study was solely qualitative and 19 in-depth interviews were conducted with all the CHOs and key health sector individuals in supervisory/coordinating positions working in urban CHPS zones to elicit relevant issues concerning urban CHPS implementation. Thematic content data analysis was done using the NVivo 7 software. RESULTS: Findings from this appraisal suggest that the implementation of this urban concept of the CHPS programme has been well undertaken by the health personnel involved in the process despite the challenges that they face in executing their duties. Several issues came to light including the lack of first aid drugs, as well as the need for the Integrated Management of Neonatal and Childhood Illnesses (IMNCI) programme and more indepth training for CHOs. In addition, the need to provide incentives for the volunteers and Community Health Committee members to sustain their motivation and the CHOs' apprehensions with regards to furthering their education and progression in their careers were key concerns raised. CONCLUSION: The establishment of the CHPS concept in the urban environment albeit challenging has been fraught with several opportunities to introduce innovations which tailor the rural milestones to meet urban needs. Modifications such as adjusting timing of home visits and renting accommodation in the communities for the CHOs have been beneficial to the programme.

Case Report: Gas in the esophagus, stomach wall and portal vein with congenital hypertrophic pyloric stenosis.

Background: CHPS dramatically affects infant growth and development and can even cause aspiration resulting from esophageal reflux. There is potential danger. CHPS is common, while CHPS with gas in the stomach wall and portal vein is rare. Gas in the stomach wall and portal vein are often the key features of more serious disease. It can be easily mistaken as a serious disease when patients with CHPS have gas in the stomach wall and portal vein. Case presentation: A 56-day-old baby was hospitalized for aspiration pneumonia after vomiting without bile for 20 days. Compared with vomiting, which is the most common symptom, pneumonia tends to attract more attention. Because of pneumonia, a chest CT scan was performed and revealed massive gas accumulation in the walls of the esophagus, stomach, and portal vein. Therefore, NEC was considered first and was treated conservatively for one week. However, the vomiting continued, and CHPS was confirmed by ultrasound. The delay in CHPS diagnosis was due to insufficient recognition of the signs of gas accumulation. Because of inexperience and lack of knowledge about CHPS with gastrointestinal pneumatosis, physicians failed to make an early accurate diagnosis. Case 2 was a 29-day-old male who was admitted to the hospital with vomiting without bile. He was examined by ultrasound, which revealed gas in the stomach wall and portal vein after admission to the hospital. No peritonitis was found after a detailed and comprehensive physical examination. Emergency life-threatening diseases such as NEC were quickly ruled out. He received surgery as soon as possible and had an uneventful recovery with no complications. Conclusion: CHPS may present with gas in the gastric or esophageal wall and portal vein, which is not a contraindication to surgery.

Effects of the community-based health planning and services on anemia and acute malnutrition amongst under-fives in Ghana: A comparative study.

Background: Ghana implemented a community-based health planning and services (CHPS) in 2000 with the aim of bringing health services to the doorsteps of the deprived in the communities. Japan International Cooperation Agency (JICA) supported the implementation of the project with a distinct approach in the Upper West region, employing supportive supervision. Objective: To investigate the impact of the JICA CHPS model on anemia and acute malnutrition prevalence amongst children less than five years of age. Methods: This is a quasi-experimental study design that compares the upper west region with the two other regions of the North implementing the traditional model of CHPS. We used the Ghana demographic and health survey dataset for 2003 as the baseline and 2014 as the follow-up year and employed the difference-in-difference approach. We find a reduction in the likelihood of anemia and acute malnutrition prevalence among children less than five years by 17 and 8 percentage points respectively. We find the project to be cost-effective, at a cost of $7 per each anemia prevalence averted. Conclusions: The results indicate that the JICA model of CHPS is cost-effective in the reduction of anemia and acute malnutrition prevalence compared to the traditional model. We recommend a nationwide expansion of the JICA model to enhance the reduction of anemia and acute malnutrition in Ghana.

Implementation of the Community-based Health Planning and Services (CHPS) in rural and urban Ghana: a history and systematic review of what works, for whom and why.

Background: Despite renewed emphasis on strengthening primary health care globally, the sector remains under-resourced across sub-Saharan Africa. Community-based Health Planning and Services (CHPS) has been the foundation of Ghana's primary care system for over two decades using a combination of community-based health nurses, volunteers and community engagement to deliver universal access to basic curative care, health promotion and prevention. This review aimed to understand the impacts and implementation lessons of the CHPS programme. Methods: We conducted a mixed-methods review in line with PRISMA guidance using a results-based convergent design where quantitative and qualitative findings are synthesized separately, then brought together in a final synthesis. Embase, Medline, PsycINFO, Scopus, and Web of Science were searched using pre-defined search terms. We included all primary studies of any design and used the RE-AIM framework to organize and present the findings to understand the different impacts and implementation lessons of the CHPS programme. Results: N = 58 out of n = 117 full text studies retrieved met the inclusion criteria, of which n = 28 were quantitative, n = 27 were qualitative studies and n = 3 were mixed methods. The geographical spread of studies highlighted uneven distribution, with the majority conducted in the Upper East Region. The CHPS programme is built on a significant body of evidence and has been found effective in reducing under-5 mortality, particularly for the poorest and least educated, increasing use and acceptance of family planning and reduction in fertility. The presence of a CHPS zone in addition to a health facility resulted in increased odds of skilled birth attendant care by 56%. Factors influencing effective implementation included trust, community engagement and motivation of community nurses through salaries, career progression, training and respect. Particular challenges to implementation were found in remote rural and urban contexts. Conclusions: The clear specification of CHPS combined with a conducive national policy environment has aided scale-up. Strengthened health financing strategies, review of service provision to prepare and respond to pandemics, prevalence of non-communicable diseases and adaptation to changing community contexts, particularly urbanization, are required for successful delivery and future scale-up of CHPS. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=214006, identifier: CRD42020214006.

Situation Analysis of a New Effort of Community-Based Health Planning and Services (CHPS) for Maternal Health in Upper West Region in Rural Ghana.

A free maternal health policy started in Ghana in 2008, however, health facility utilization is still low, and out-of-pocket payments (OOPPs) are putting households at risk of catastrophic expenditure. To improve this situation, some rural communities have assigned a midwife to a health post called community-based health planning and services (CHPS), where only assistant nurses are allocated. This study explored the effectiveness of the new approach in Upper West Region, Ghana. We conducted a cross-sectional study and interviewed women who gave birth in the last year. We systematically selected communities matched into four criteria: communities near CHPS (functional CHPS), communities near CHPS with a midwife (advanced CHPS), communities near a health centre, and communities without a health facility in their neighbourhood. In total, 534 women were interviewed: functional CHPS 104, advanced CHPS 131, near health centre 173, and no facility 126. About 78% of the women were 20 to 34 years old. About half of the women incurred OOPP, however, catastrophic payment (household spending > 5% of annual income) was significantly lower in advanced CHPS communities for normal delivery compared with the other three communities. The new local approach of assigning a midwife to CHPS functioned well, improving access to healthcare facilities for childbirth.

The effect of the capitation policy withdrawal on maternal health service provision in Ashanti Region, Ghana: an interrupted time series analysis.

BACKGROUND: Payment methods are known to influence maternal care delivery in health systems. Ghana suspended a piloted capitation provider payment system after nearly five years of implementation. This study aimed to examine the effects of Ghana's capitation policy on maternal health care provision as part of lesson learning and bridging this critical literature gap. METHODS: We used secondary data in the District Health Information Management System-2 and an interrupted time series design to assess changes in level and trend in the provision of ANC4+ (visits of pregnant women making at least the fourth antenatal care attendance per month), HB36 (number of hemoglobin tests conducted for pregnant women who are at the 36th week of gestation) and vaginal delivery in capitated facilities-CHPS (Community-based Health Planning and Services) facilities and hospitals. RESULTS: The results show that the capitation policy withdrawal was associated with a statistically significant trend increase in the provision of ANC4+ in hospitals (coefficient 70.99 p < 0. 001) but no effect in CHPS facilities. Also, the policy withdrawal resulted in contrasting effects in hospitals and CHPS in the trend of provision of Hb36; a statistically significant decline was observed in CHPS (coefficient - 7.01, p < 0.05) while that of hospitals showed a statistically significant trend increase (coefficient 32.87, p < 0.001). Finally, the policy withdrawal did not affect trends of vaginal delivery rates in both CHPS and hospitals. CONCLUSIONS: The capitation policy in Ghana appeared to have had a differential effect on the provision of maternal services in both CHPS and hospitals; repressing maternal care provision in hospitals and promoting adherence to anemia testing at term for pregnant women in CHPS facilities. Policy makers and stakeholders should consider the possible detrimental effects on maternal care provision and quality in the design and implementation of per capita primary care systems as they can potentially impact the achievement of SDG 3.

Towards quality primary health care: the dilemma of Community-Based Health Planning and Services (CHPS) in health service provision in Ghana.

PURPOSE: Over the past two decades, Community-Based Health Planning and Services (CHPS) has been a pragmatic strategy towards universal Primary Health Care (PHC) in Ghana. However, the ability and capacity of these facilities to deliver quality primary health care remain an illusion as they are still crumbling in myriad challenges. These challenges are translated to the poor-quality services provision and low community utilization of CHPS facilities. The study presents a comparative analysis of three communities in the Kassena-Nankana East Municipality, Ghana. DESIGN/METHODOLOGY/APPROACH: Using a mixed-method research design, the study gathered and analysed data from 110 households, three community health officers (CHOs) and three community leaders using semi-structured questionnaires and interview guides. FINDINGS: The findings indicated that the facilities do not have the requisite inputs such as drugs and supplies, logistics, appropriate health personnel, good infrastructure, funding support necessary to deliver quality and appropriate healthcare services that meet the health needs of the communities. For the CHPS to realize their full potentials as PHC facilities, it is required that the needed inputs such as logistics, drugs and appropriate staff are in place to facilitate the activities of CHOs. RESEARCH LIMITATIONS/IMPLICATIONS: Due to the limited number of participants and selection of the study communities, the results may generalization. Also, the researchers acknowledged the inability to interview the district level health officials and the Kassena-Nankana Municipal Assembly during the field visits. This could have provided in-depth knowledge on the findings of this research as well as the validation of the results from the communities' perspective. Several attempts were made to contact and interview district-level authorities which proven futile due to the unavailability of targeted respondents. This resulted in limiting the studies at the community level. However, this limitation does not disprove the findings of this study. PRACTICAL IMPLICATIONS: The article implications for planning primary health care strategies include a keen assessment of community health needs and institutional management of primary health care facilities, equip PHC facilities with adequate resources such as drugs and appropriate staffing to provide the health needs of the communities. ORIGINALITY/VALUE: The paper fulfils the gap in the literature by providing empirical data on how the challenges of primary health care facilities affected the provision of high quality service and how this can affect community's use of the facilities.

Willing but unable? Extending theory to investigate community capacity to participate in Ghana's community-based health planning and service implementation.

While primary health care programmes based on community participation are widely implemented in low- and middle- income settings, empirical evidence on whether and to what extent local people have the capacity to participate, support and drive such programmes scale up is scant in these countries. This paper assessed the level of community capacity to participate in one such programme - the Community-Based Health Planning and Service (CHPS) in Ghana. The capacity assessments were drawn from Chaskin's (2001) theorised indicators of community capacity with modifications to include: sense of community; community members commitment; community leadership commitment; problem solving mechanisms; and access to resources. These capacity measures guided the design of an interview guide used to collect data from community informants, frontline health providers (FLP) and district health managers. Key qualitative themes were built into a questionnaire administered to households selected through systematic sampling approach. Findings showed that growing individualism, low trust in neighbours and apathetic behaviours undermined the capacity of mutual support for CHPS. The capacity to support CHPS was high for local leadership and community social mobilisation groups who often dedicated time to working with FLP to promote maternal and reproductive health service use, and in advocating broader support for CHPS. Within the wider community, commitment to voluntarism was low as members perceived CHPS to be owned by, and run on government funds and resources. Poor voluntarism was compounded by poverty that crippled the capacity to provide needed resource support for CHPS. Findings have great implications for building strong capable communities for participation in community oriented health programmes.

The status of Ghanaian community health workers' supervision and service delivery: descriptive analyses from the 2017 Performance Monitoring and Accountability 2020 survey.

Introduction: Community-based services are a critical component of high-quality primary healthcare. Ghana formally launched the National Community Health Worker (CHW) program in 2014, to augment the pre-existing Community-based Health Planning and Services (CHPS). To date, however, there is scant data about the program's implementation. We describe the current supervision and service delivery status of CHWs throughout the country. Methods: Data were collected regarding CHW supervision and service delivery during the 2017 round of the Performance Monitoring and Accountability 2020 survey. Descriptive analyses were performed by facility type, supervisor type, service delivery type, and regional distribution. Results: Over 80% of CHWs had at least monthly supervision interactions, but there was variability in the frequency of interactions. Frequency of supervision interactions did not vary by facility or supervisor type. The types of services delivered by CHWs varied greatly by facility type and region. Community mobilization, health education, and outreach for loss-to-follow-up were delivered by over three quarters of CHWs, while mental health counseling and postnatal care are provided by fewer than one third of CHWs. The Western region and Greater Accra had especially low rates of CHW service provision. Non-communicable disease treatment, which is not included in the national guidelines, was reportedly provided by some CHWs in nine out of ten regions. Conclusions: Overall, this study demonstrates variability in supervision frequency and CHW activities. A high proportion of CHWs already meet the expected frequency of supervision. Meanwhile, there are substantial differences by region of CHW service provision, which requires further research, particularly on novel CHW services such as non-communicable disease treatment. While there are important limitations to these data, these findings can be instructive for Ghanaian policymakers and implementers to target improvement initiatives for community-based services.

Challenges to achieving universal health coverage through community-based health planning and services delivery approach: a qualitative study in Ghana.

OBJECTIVE: Community-based initiatives have enormous potential to facilitate the attainment of universal health coverage (UHC) and health system development. Yet key gaps exist and threaten its sustainability in many low-income and middle-income countries. This study is first of its kind (following the launch of the Sustainable Developments Goal [SDG]) and aimed to holistically explore the challenges to achieving UHC through the community-based health planning and service (CHPS) initiative in Ghana. DESIGN: A qualitative study design was adopted to explore the phenomenon. Face-to-face indepth interviews were conducted from April 2017 until February 2018 through purposive and snowball sampling techniques. Data were analysed using inductive and deductive thematic analysis approach. SETTING: Data were gathered at the national level, in addition to the regional, district and subdistrict/local levels of four regions of Ghana. Sampled regions were Central Region, Greater Accra Region, Upper East Region and Volta Region. PARTICIPANTS: In total, 67 participants were interviewed: national level (5), regional levels (11), district levels (9) and local levels (42). Interviewees were mainly stakeholders-people whose actions or inactions actively or passively influence the decision-making, management and implementation of CHPS, including policy makers, managers of CHPS compound and health centres, politicians, academics, health professionals, technocrats, and community health management committee members. RESULTS: Based on our findings, inadequate understanding of CHPS concept, major contextual changes with stalled policy change to meet growing health demands, and changes in political landscape and leadership with changed priorities threaten CHPS sustainability. CONCLUSION: UHC is a political choice which can only be achieved through sustainable and coherent efforts. Along countries' pathways to reach UHC, coordinated involvement of all stakeholders, from community members to international partners, is essential. To achieve UHC within the time frame of SDGs, Ghana has no choice but to improve its national health governance to strengthen the capacity of existing CHPS.

Does the provision of community health services offset the effects of poverty and low maternal educational attainment on childhood mortality? An analysis of the equity effect of the Navrongo experiment in Northern Ghana.

The Government of Ghana has instituted a National Poverty Reduction Program with an initiative known as the Community-based Health Planning and Services (CHPS) as its core health development strategy. CHPS was derived from a plausibility trial of the Navrongo Health Research Centre testing four contrasting primary health care strategies: i) Training unpaid volunteers to promote health in communities, ii) placing nurses in communities with training and supplies for treating childhood illnesses, iii) combining the nurse and volunteer approaches, and iv) sustaining a comparison condition whereby clinic services were provided without community resident workers. This paper presents an age-conditional proportional hazard analysis of the long term impact of community health worker exposure among 94,599 children who were ever under age five over the January 1, 1995 to December 2010 period, adjusting for age conditional effects of shifts in exposure type as CHPS was scaled up in Navrongo project area over the 1995-2000 period. Results show that children whose parents are uneducated and relatively poor experience significantly higher mortality risks than children of the educated and less poor. Conditional hazard regression models assess the impact of CHPS on health equity by estimating the interaction of equity indicators with household exposure to CHPS service operations, adjusting for age conditional exposure to original Community Health and Family Planning Project (CHFP) service strategies as scale-up progressed. The association of mortality risk among children with uneducated and relatively impoverished mothers is offset by exposure to community health nursing services. If exposure is limited to volunteer-provided services alone, survival benefits arise only among children of relatively advantaged households. Findings lend support to policies that promote the CHPS nurse approach to community-based services as a core health component of poverty reduction programs.

Ghana's community-based primary health care: Why women and children are 'disadvantaged' by its implementation.

Policy analysis on why women and children in low- and middle-income settings are still disadvantaged by access to appropriate care despite Primary Health Care (PHC) programmes implementation is limited. Drawing on the street-level bureaucracy theory, we explored how and why frontline providers (FLP) actions on their own and in interaction with health system factors shape Ghana's community-based PHC implementation to the disadvantage of women and children accessing and using health services. This was a qualitative study conducted in 4 communities drawn from rural and urban districts of the Upper West region. Data were collected from 8 focus group discussions with community informants, 73 in-depth interviews with clients, 13 in-depth interviews with district health managers and FLP, and observations. Data were recorded, transcribed and coded deductively and inductively for themes with the aid of Nvivo 11 software. Findings showed that apart from FLP frequent lateness to, and absenteeism from work, that affected care seeking for children, their exercise of discretionary power in determining children who deserve care over others had ripple effects: families experienced financial hardships in seeking alternative care for children, and avoided that by managing symptoms with care provided in non-traditional spaces. FLP adverse behaviours were driven by weak implementation structures embedded in the district health systems. Basic obstetric facilities such as labour room, infusion stand, and beds for deliveries, detention and palpation were lacking prompting FLP to cope by conducting deliveries using a patchwork of improvised delivery methods which worked out to encourage unassisted home deliveries. Perceived poor conditions of service weakened FLP commitment to quality maternal and child care delivery. Findings suggest the need for strategies to induce behaviour change in FLP, strengthen district administrative structures, and improve on the supply chain and logistics system to address gaps in CHPS maternal and child care delivery.