The Institute for Global Health and Development

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PROMOTING HEALTH SYSTEMS RESILIENCE IN THE FRAGILE CONTEXT OF NORTHERN GHANA: A STUDY OF COMMUNITY-BASED HEALTH PLANNING AND SERVICES (CHPS) EFFECTIVENESS
(Queen Margaret University, Edinburgh, 2024-05-08) Azasi, Esther
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.