lessons learned from scaling up a community-based health ... · key scaling-up lessons: (1) place...

ORIGINAL ARTICLE

Lessons learned from scaling up a community-based healthprogram in the Upper East Region of northern GhanaJohn Koku Awoonor-Williams,a Elias Kavinah Sory,b Frank K Nyonator,b James F Phillips,c

Chen Wang,c Margaret L Schmittc

The original CHPS model deployed nurses to the community and engaged local leaders, reducing childmortality and fertility substantially. Key scaling-up lessons: (1) place nurses in home districts but not homevillages, (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 inanother setting, pilot the approach locally, and expand based on lessons learned.

ABSTRACTGhana’s Community-Based Health Planning and Service (CHPS) initiative is envisioned to be a nationalprogram to relocate primary health care services from subdistrict health centers to convenient communitylocations. The initiative was launched in 4 phases. First, it was piloted in 3 villages to develop appropriatestrategies. Second, the approach was tested in a factorial trial, which showed that community-based carecould reduce childhood mortality by half in only 3 years. Then, a replication experiment was launched toclarify appropriate activities for implementing the fourth and final phase—national scale up. This paperdiscusses CHPS progress in the Upper East Region (UER) of Ghana, where the pace of scale up has beenmuch 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) nurserecruitment from their home districts to improve worker morale and cultural grounding, balanced with somesocial distance from the village community to ensure client confidentiality, particularly regarding familyplanning use; (2) prioritization of CHPS planning and continuous review in management meetings to makenecessary modifications to the initiative’s approach; (3) community engagement and advocacy to localpoliticians to mobilize resources for financing start-up costs; (4) a shared and consistent vision about CHPSamong 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 andscale up within and between districts.

INTRODUCTION

C ommunity-based health services programs arebeing launched and expanded throughout sub-

Saharan Africa. Yet clinic-focused services remain themainstay of most of these programs despite several

convincing demonstrations that community-basedoperations can be more effective if static services areaugmented with active provision of doorstep care.1-4

Even the most successful of these small-scale projectsoften fail to be mainstreamed into large-scale opera-tions, because experimental trials generally use manyresources that are challenging to replicate in large-scale operations.5 Moreover, when doorstep serviceinnovations are expanded beyond original target areas,a complex process of instituting system-wide adjust-ments to new supervisory structures, leadershipdynamics, policies, resource allocation strategies, and

a Ghana Health Service, Upper East Regional Health Administration,Bolgatanga, Ghanab Ghana Health Service, Accra, Ghanac Columbia University, Mailman School of Public Health, New York City, NewYork, USA

Correspondence to James Phillips ([email protected])

Global Health: Science and Practice 2013 | Volume 1 | Number 1 1

plans are needed at each organizational level.6

Such systemic changes are more complex toundertake than donors, researchers, and plan-ners typically anticipate,7 largely because leader-ship required to develop and test small-scaleinnovations sometimes contrasts with the type ofmanagerial and political leadership required tochange a large-scale system.

As early as the 1978 Alma Ata Conference,policies for achieving community-based primaryhealth care became a pillar of Ghana’s healthpolicies. By the 1990s, however, mountingevidence that health development was notachieving national goals stimulated deliberationson feasible means of achieving health-sectorreform.8-13 Moreover, the specific means ofimproving program performance remainedunclear.14-15 Research identifying gaps in healthoutcomes called for national solutions, yet therewas little concrete guidance to evidence-basedpolicymaking and program development.

This paper describes the history of how anexperimental study set the stage for a nationalprogram for promoting community-based pri-mary health care—the Community-Based HealthPlanning and Services (CHPS) initiative. Thepaper also discusses factors of the initiative in theUpper East Region (UER) where CHPS wasoriginally tested and scale up was most success-ful, despite being Ghana’s poorest and mostremote region. After a decade of implementation,the population of CHPS communities served bythe CHPS program as a proportion of totaldistrict populations in the UER was 5 times thecoverage achieved in the other 9 regions. Toclarify factors that could explain the relativesuccess of scale up, we consulted current andformer Regional and District Directors ofHealth Services in the UER and compared theirinsights with those of leaders from an adjacentregion where CHPS has been relatively slow toscale up.

WHAT IS CHPS?

CHPS is a national health policy to reorientprimary health care services from subdistricthealth centers to convenient community loca-tions. Its goal is to transform the dynamics ofrural health care service delivery from commu-nity health care providers who passively waitfor patients into outreach workers who activelyseek patients in communities and their homes,also known as doorstep services. The vision

of CHPS is to accelerate progress towardMillennium Development Goals 4 and 5 (MDG4 and 5) on child health and maternal health,respectively. The core strategy entails deployingtrained and salaried nurses, known as commu-nity health officers (CHOs), to village locationswhere they provide basic preventive, curative,and promotional health services in homes orcommunity clinics. The CHOs are supported bythe health care program’s community organiza-tional activities, including the recruitment, train-ing, and deployment of volunteer workers.Critically important to CHPS is the effectiveprovision of family planning information andservices, to include doorstep provision of oral,injectable, and barrier contraception, referralfor IUDs and other long-acting methods, andpromotional services that are targeted to theneeds of men and organized mainly by malevolunteers.16-17

PHASED PROGRAM DEVELOPMENT OFCHPS

Beginning in the early 1990s, Ghana instituted apartnership between applied health researchersand administrators to develop an action-orientedresearch agenda to guide health sector reform byresolving policy debates.18 CHPS was informedsignificantly by national program developmentexperience in Asia.19 It was initially developed asa pilot project of the Navrongo Health ResearchCentre and progressed into a national policy over4 overlapping phases (Figure 1).

Phase 1: Navrongo Pilot to Develop SocialGrounding for Service StrategiesIn Navrongo, Kassena-Nankana District, UER, an18-month pilot was initiated in 1994 by a team ofsocial researchers, health scientists, and programimplementers. The team consulted chiefs andelders, married women and men, and healthcare providers about appropriate strategies forimplementing, managing, and sustaining com-munity-engaged primary health care14 in orderto subordinate operation of the program to socialinstitutions that shape reproductive preferencesand health-seeking behavior.20-21 Researchscientists conducted qualitative research todetermine the form of social interaction neces-sary for simplifying health communication andprogram mobilization processes and for facilitat-ing volunteerism, consensus building, and idea-tional change. Qualitative research also identified

Leadership todevelop small-scale innovationsis often differentthan the type ofmanagerial andpolitical leader-ship required tochange systems atscale.

Lessons from scale up of a community-based health program in Ghana www.ghspjournal.org


gender issues and possible strategies for address-ing them,22 including how to offset gate-keepingconstraints in seeking health care,23 how toengage the support and participation of men inreproductive health promotional activities thatthey might otherwise resist,24 and how to sustainworker accountability for responsible servicedelivery.17 Focus group discussions were con-ducted quarterly to understand health workerand community reactions and to revise and tailorprogram operations. Following 18 months of thisparticipatory research and planning, an appro-priate model was finalized.25

Two sets of activities emerged from the Phase1 model:

1. Existing clinical nurses were reoriented tocommunity health care and assigned to villagelocations with the new designation of ‘‘com-munity health officers’’ (CHOs). Nurses com-pleted 18 months of training focused on basiccurative health services, public health, immu-nization, and family planning.

2. Male volunteers from the communities wererecruited and trained for 6 weeks to provide alimited set of services, such as oral rehydra-tion and provision of condoms (Box 1). Thesezurugelu (‘‘togetherness’’) activities werebased on existing traditional forms of gover-nance, consensus building, and volunteerism,and they were designed to build male leader-ship and participation into reproductivehealth services, in addition to expandingwomen’s participation in seeking reproduc-tive and child health services. The projectequipped volunteers with bicycles and start-up kits of essential drugs, conducted trainingon service management, and set up revolvingaccounts so that the community financed andsustained the flow of supplies.26

During Phase 1, the project clarified, docu-mented, and translated operational details ofmobilizing zurugelu and community healthofficer activities into practical and culturallyappropriate implementation plans.17 See Box 2

FIGURE 1. Phases in the Ghana Program Development Process

Phase 1: Navrongo

Pilot (1994-1996)

Candidate System

Culturally appropriate

system

Open-systems micro pilot

What is aculturally

appropriate system of care?

Phase 2: Navrongo

Experiment(1996-2003)

Evidence that the system could

work

Mortality and fer�lity impact

Plausibility trial

Does thecandidate

system work?

Phase 3: Replica�on in Nkwanta

(1998-2004)

Model for scaling up

Replicable strategy

Implementa�on research

Is the system replicable and sustainable?

Phase 4: Na�onal Scale Up

(2000-present)

Reformed na�onal program

Coverage

Organiza�onal change and

development

Is coverage expanding?

PRODUCT

ENDPOINT

PARADIGM

QUESTION

Source: Reference 14.



Box 1. Community Health Services Piloted in Phase 1

Role of nurses, known as community health officers (CHOs), who received 18 months of technicaltraining and provided both health post-based and doorstep services:

N Integrated management of childhood illness (treatment of malaria and febrile acute respiratoryinfection with antibiotics), management of diarrheal disease, and referral of complicated cases

N Outreach organizational support for comprehensive childhood immunization

N Provision of micronutrient supplementation

N Antenatal care, including the provision of iron folate

N Support for uncomplicated deliveries and referral for emergencies

N First aid for minor injuries and skin conditions

N Health promotion and education, including supervisory support for volunteers

N Family planning counseling and services (oral contraception, condom distribution, and injectablecontraception) and referral for long-acting methods

N Management of contraceptive side effects and referral, as needed

Role of male volunteers, who were selected by community stakeholders and trained for6 weeks:

N Antipyretics for the care of children

N Oral rehydration

N Condoms

N Vitamin supplementation

N Health and family planning promotion directed mainly to male social networks

N Organizational backstopping of CHO activities, such as immunization and antenatal care

Box 2. Key Lessons from the Phase 1 Navrongo Pilot

N Community-based consultation is an effective means of adapting strategies to the socialenvironment. Traditional social structures can be successfully engaged as a programmaticgoverning body—in this case, the chieftaincy and lineage system.

N Collaboration between community leaders, implementers, and social scientists permitted‘‘learning by doing’’—adjustments of strategy according to new evidence, community advice,and worker comments. Operational aspects involving selection and training of workers andvolunteers, as well as gender and communication strategies, work routines, location of healthposts, and other operational details, can be optimized with ‘‘learning by doing’’ communityinput.

N Appropriate worker recruitment strategies need to be developed to address Ghana’s cultural andlanguage diversity. (Ghana has 82 languages.) National centralized recruitment and training offrontline workers lead to the deployment of staff who lack basic linguistic skills and culturalknowledge. District-level decentralized manpower development reduces turnover and improvesperformance.

N Workers should be posted to their home district but not to their home village. Villages seek nurseswho have an element of social distance and an ability to maintain family planning confidentiality.For this reason, the project constructed ‘‘community health posts’’ to provide a balance betweenintegrating services into the local context and maintaining social distance between the service andsocial system.



for key lessons learned during the firstphase.

Phase 2: Navrongo Experimental Trial toTest the Pilot ApproachFollowing the pilot, 37 communities of Kassena-Nankana District were grouped into experimen-tal areas where zurugelu and CHO activities weredeployed. Subdistricts were assigned to 1 of 4experimental groups to evaluate the relativeefficacy of the approaches (Figure 2):16

1. Zurugelu activities

2. CHO activities

3. Both zurugelu and CHO activities

4. No intervention

Relative efficacy was evaluated with data onchild mortality and fertility trends collected bythe Navrongo Demographic Surveillance System(NDSS).16,27,28

Results indicated that comprehensive com-munity-based health care provided by the CHOs

with support from zurugelu volunteers wasassociated with statistically significant reduc-tions in fertility rates and substantial improve-ments in child survival compared with otherexperimental groups.29-30 In the first 3 years ofthe project, the total fertility rate declined by 1birth in the combined CHO and zurugelucommunities while it remained unchanged atnearly 5.5 in the comparison areas. In thecommunities where CHOs were deployed—whether with or without zurugelu volunteers—child mortality declined by one-half in only 3years. Within 7 years, child mortality declined bytwo-thirds.

Communities in which CHOs were deployedbut without support from community volunteersshowed no changes in fertility rates. In addition,there was no fertility or mortality impact in thesubdistricts where only zurugelu activities wereimplemented. In fact, volunteers posted withoutresident CHOs were less effective than providingno community care at all.22,31 The non-interven-tion group was also ineffective, experiencing

FIGURE 2. Navrongo Experimental Trial Intervention Groups, Kassena-Nankana District, Ghana

Ghana

Kilometers

0 10 20

1

4

Health center

Zurugelu volunteers only

No intervention

Both Zurugelu volunteers and CHOs

2

2

3

3

**

**

*

1 -

2 -

4 -

3 -

Intervention Groups:


Deploying nurses,with support fromcommunity volun-teers, substan-tially reduced bothfertility and childmortality rates.



modest demographic changes unrelated to com-munity-based care.

Because the CHO plus zurugelu approachproduced improvement in both reproductiveand child health, the combined approach wasdeemed to be the optimal strategy for nationalscale up.29-30,32-33 See Box 3 for lessons learnedduring the second phase.

Phase 3. Replication Experiment in OtherDistricts to Validate ApproachesAlthough results of the Navrongo trial wereimpressive, district and regional health managersquestioned relevance of the model to a nationalprogram. They debated whether replication ofthis model could be achieved in other parts ofGhana and whether it would improve demo-graphic and health outcomes in areas outside theUER. Critics asserted that non-replicable institu-tional resources of the Navrongo Health ResearchCentre were responsible for the project’s success,compromising relevance of the approach in othersettings. Others argued that the Navrongo modelwas relevant only to the sociocultural circum-stances of the UER.

To gain the necessary credibility for launch-ing a national scale up of the model, theNavrongo experience was validated in anothercultural and ecological zone of Ghana—therural Nkwanta District of the Volta Region—whereby only routinely available resources of theGhana Health Service (GHS) were used.14-15

To facilitate this process, the Volta RegionalHealth Administration sponsored a ‘‘knowledgeexchange,’’ in which health workers fromNkwanta District visited the Navrongo projectteam in Kassena-Nankana to observe theNavrongo model of care and engage in candiddiscussions with counterparts about the feasi-bility of transferring the Navrongo model toNkwanta. Although participants viewed the

transfer of the model as requiring a dauntingexpansion of logistics capabilities, manpower,and supervisory workloads, direct dialogue withthe Navrongo project team dispelled mysteryabout the CHPS development process and nur-tured teamwork for developing pilot CHPS areasin Nkwanta.34

To facilitate implementation, the Nkwantamanagement team adopted Navrongo’s partici-patory planning process for adapting strategies tolocal and contextual circumstances as severaldistinct differences existed between the Nkwantaand Kassena-Nankana Districts, including theirsocial organizational structures. Moreover,Navrongo had extensive research resources thatthe Nkwanta team lacked. Thus, the Nkwantateam developed training, logistics, and manage-ment information procedures that could beimplemented at minimal cost.34-35

The exchange program achieved operationalsuccess and contributed to increased healthaccess and use.35-36 In response, the GHSsponsored additional replication projects so thateach region of Ghana would have learninglocalities where CHPS could be implementedusing the Nkwanta scaling-up strategy. In eachreplication district, the community-based caremodel increased contraceptive prevalence, parti-cipation in antenatal and postnatal care, andchildhood immunization coverage.34,36

The success of the multidistrict replicationprocess suggested that the Navrongo modelcould be implemented in similarly impoverishedand health-deprived localities even with con-trasting administrative, social, and cultural sys-tems (Box 4). The exchange program alsodemonstrated that inter-district peer-exchangeprograms could be used to scale up CHPS.40-41,14

Most importantly, monitoring evidence sug-gested that participatory team exchanges werea more successful strategy for fostering scale up

Box 3. Key Lessons from the Phase 2 Navrongo Experimental Trial

N The combination of traditional social institutions and volunteers with community health nurses,relocated from subdistrict health center clinics to communities, maximizes social acceptability ofhealth and family planning care.

N The combined CHO and zurugelu volunteers approach produced substantial improvements inboth fertility and child mortality rates.

N Piecemeal approaches do not work: Volunteer-based outreach without a resident CHO had noimpact on fertility or child mortality; CHO-based services without the support of volunteers had nofamily planning and fertility impact.

Exchange visitsbetween newlyimplementing andadvanced teamswere more suc-cessful at scalingup the CHPSmodel than tradi-tional workshops.



than workshops. Indeed, even today, most CHPScoverage is concentrated in districts that parti-cipated in exchanges with the Navrongo orNkwanta teams. Much of the success withCHPS scale up in the UER is related to the factthat all workers in the region have had experi-ence with the process of developing and imple-menting CHPS, even before they started theprocess in their home localities.15

Phase 4. National Expansion of the CHPSInitiativeIn 1999, the GHS reconvened district andregional health managers to assess theNkwanta validation experience, and consensusemerged for promoting lessons from theKassena-Nankana and Nkwanta Districts into anational program (Box 5). According to monitor-ing data from the GHS,42 nearly all districts inGhana had some degree of coverage of the CHPSprogram by 2008 (Figure 3). Further observationand monitoring indicated that CHPS spread most

rapidly in districts where pilots had beenlaunched, suggesting that scale up followedpatterns of change characteristic of diffusionprocesses.15,43

CHPS SCALE-UP CHALLENGES AND UPPEREAST REGION SOLUTIONS

Monitoring data from September 2000 to June2008 indicate that the proportion of the popula-tion covered by functioning CHPS zones acrossGhana’s 10 regions is low, with the mostpopulous regions in southern Ghana performingthe most poorly (Figure 4). The national trend ofCHPS scale up in Ghana during this time periodis also low (indicated by the black line inFigure 4). In contrast, the prevalence of CHPScoverage in the UER was 5 times that of thenational average as of mid-2008. Further pro-gress since 2008 has sustained the region as theleader among all 10 regions and the only regionon target to attain full coverage by 2015.

Box 4. Key Lessons from the Phase 3 Replication Trial

N Knowledge exchange visits between new and experienced CHPS districts can catalyze the transferof CHPS implementation capabilities.

N While CHO doorstep service delivery is the core component of CHPS, optimizing implementationrequires adjustment to social and ecological conditions of each district. CHPS operational detailsshould be locally planned and decentralized.

N Cultural heterogeneity requires strategic decentralization. Sustaining and spreading the Phase 1pilot learning process informs and catalyzes scaling up.

N Redesigning training manuals to address technical inadequacy and improving documentation sothat manuals are system implementation-focused rather than focused solely on healthinterventions was necessary.

N Decentralizing human resource development to the regional level ensured linguistic and culturaldiversity were not constraints to scale up.

Box 5. Key Lessons from Phase 4 National Scale Up

Because core financing for CHPS is lacking, relying on other strategies helped to mobilize thenecessary resources and accelerate scale up. These included:

N Funding ‘‘pilot CHPS’’ zones within districts that give managers experience while politicians canobserve operations and witness community enthusiasm for CHPS. Let the political gains of CHPSexpansion become a political gain for local assemblymen and assemblywomen.

N Seeking local government and community support to fund start-up costs while health sectormanagers seek financing from the development sector for expansion costs

N Prioritizing CHPS in regional staff meetings, budget discussions, and data review to catalyzeorganizational change. Follow through with regional technical staff visits to districts and CHPSzones, making CHPS expansion a key factor in performance reviews.



Methodology for Assessing Views ofDistrict DirectorsTo clarify stakeholder’s perceptions of factorsthat either constrained or accelerated the scaleup of CHPS in the UER, we interviewed allformer and current District Directors of HealthServices, 3 former and current Regional Directorsof Health Services, and key staff and scientistsof the Navrongo Community Health and FamilyPlanning Project. For comparison, we inter-viewed the current Regional Director of theNorthern Region and District Directors ofHealth Services in 4 northern regional healthadministrations. We also conducted a deskreview of archival reports and documents ofthe GHS.

We identified 2 sets of challenges to scalingup the CHPS program.

In general, issues related to manpowernumbers, training, service capacity, anddeployment summarized in Table 1 apply to

the early CHPS implementation era. For exam-ple, CHOs in the early phases were unprepared todeliver essential health services, such as addres-sing maternal and neonatal complications. Inaddition, the initial training program for CHOsdid not provide them with the necessary skills inhow to engage with the community. Since 2009, aproject of the GHS known as the Ghana EssentialHealth Intervention Programme (GEHIP) hasfocused on diagnosing barriers to CHPS expan-sion and developing interventions to addressthese problems. For example, the project trainedCHOs in strategies for saving newborn lives andimplemented a referral system to manage com-plicated cases.

Table 2 summarizes constraints related tosupport systems for expanding CHPS, main-taining operations, and leading the programdevelopment process. For instance, stake-holders pointed to the complicated health man-agement information system that overburdened

FIGURE 3. Geographic Density of CHPS Coverage by District, Ghana, January 2001 and July2008

January 2001 July 2008 % of Popula�on Covered by CHPS Services

< 10%

10% - 20%

21% - 30%

31% - 40%

41% - 50%

51% - 60%

61% - 70% 71% - 80%

81% - 90%

> 90%

Abbreviations: CHPS, Community-Based Health Planning and Services.




staff to the detriment of service delivery.Furthermore, lack of feedback on the collecteddata resulted in little use of the informationto improve service delivery. In many districts,lack of leadership and political engagement,coupled with the absence of a budget lineitem for CHPS, resulted in inadequate resourcesand a lack of focus on and clarity about theprogram.

5 Strategies for Sustaining andAccelerating Scale Up in the UERInterviews with the district and regional direc-tors revealed 5 common strategies in the UERto cope with these challenges, which facilitatedbetter scale up in the region compared with otherregions.

Appropriate Manpower Recruitment, Training, andDeployment StrategiesDue to the close proximity of the the NavrongoCentre to the Regional Health Administration inthe UER, which deploys CHOs, the operationaldetails of launching, sustaining, and scaling up alarge cadre of community nurses, including

developing appropriate strategies for selectingtrainees, has always been well understood byregional health leaders. Before 2002, the UERlacked a community health nursing school, andmost nurses came from outside the region. Theyoften did not speak local languages, and it waschallenging to find nurses for community reloca-tion who had the cultural understanding thatcommunity work required. As one district direc-tor noted:

It is all about commitment. When meet[ingwith] them we plead with them because weknow [it] is not easy traveling every day inand out … [and it] is risky. It’s very difficultfor us to draw [nurses] from [subdistrict]health centers. Some are pregnant, some are goingto school, [and] some are joining their newhusbands.

In response, the UER opened a regionaltraining school in Navrongo and pioneered apolicy of recruiting nurse trainees from thedistricts to which they would be posted. Thecommunities themselves nominate and finan-cially support most nurse candidates to ensure

FIGURE 4. Percentage of the Population Served by Workers of the CHPS Program, by Region andNationwide, September 2000 to June 2008

Brong Ahafo

Ashanti

Regions40%

35%

30%

25%

20%

15%

10%

2001

2002

2003

2004

2005

2006

2007

2008

5%

0%

Northern

Upper West

Upper East

Greater Accra

Volta

Western

Central

Eastern

Ghana

Abbreviations: CHPS, Community-Based Health Planning and Services.




language competency. This early attention to‘‘community-engaged’’ manpower developmenthas catalyzed scale up. Unlike in other regions,where nurses are often unfamiliar with theirplace of assignment, CHOs graduating from theUER training school in Navrongo return home towork among their own community. In 2004, theyear the first group of nurses graduated fromthe Navrongo training school, all districts in theregion witnessed an increase in the number offunctional CHPS.

Evidence-Based Review and Modification of CHPSStrategiesResults of the Navrongo research project wereshared with the District Health ManagementTeams (DHMTs) from the onset of the experi-ment, which provided district managers with theevidence needed to convince them to make thenecessary changes in operations. Furthermore, acontinuous review of research in managementmeetings and a general climate of openness tothe role of research in guiding action prompted

TABLE 1. CHPS Scaling-Up Constraints and Responses in the Upper East Region (UER) Related to Recruitment,Training, and Deployment of Community Health Officers

Constraint Type Barriers to Scaling Up Actions Implemented in the UER Global Implications

Limited rangeof services

N Deficient range of services.Community health officers(CHOs) were unprepared foressential services (midwifery,emergency management,immediate post-delivery care).

N Over-extension of jobdescriptions

N Piloted and scaled upcommunity-engaged refer-ral system

N Trained CHOs in strategiesfor saving newborn lives

N Focus roles on the burdenof disease and family plan-ning

N Risk transition. Community-basedprimary health care reduces the burdenof disease. Emergency-related causescomprise an increased proportion ofthe remaining unaddressed burden.

N Community-based planning.Developing effective referral systemsrequires adapting operations to com-munity road conditions and commu-nication needs.

InappropriateCHOrecruitment

N Insufficient nurse manpower

N Centralized recruitment resultsin deployment of workers tolocalities where they are notconversant with locallanguages or customs.

N Expanded nurse trainingschool volume

N Recruited trainees fromdistricts where they are tobe assigned and involvedhealth committees in selec-tion process

N Bottom-up planning. Communityhealth systems development requires‘‘bottom up’’ strategic planning so thatscale up builds capacity that effectivelylinks services to local cultural condi-tions, languages, and health needs.

N Plan for ethnic diversity. Community-engaged recruitment reduces turnoverand improves performance, morale,and community ownership.

InappropriateCHO training

N Pre-service training. Existing18-month training programdoes not address communityengagement, service outreach,and community health careplanning. Overreliance ondidactic training and shortageof locations and equipment formentoring arrangements hin-der CHO preparedness.

N In-service training. Relocatingnurses from clinics to villagesrequires training them to becommunity organizers withliaison and diplomatic skills.

N Implemented 6-monthregional CHO internshipsfocused on communityengagement

N Organized peer mentoringcoordinated with the train-ing school curriculum

N Systems approach to manpowerdevelopment. Equipment and bud-getary planning should integrate theprocess of pre-service, internship,and in-service training and plan forpeer-mentoring arrangements.

N Community-engaged peer leader-ship. Didactic health technology train-ing is insufficient.

Community in-volvement innurse selectioncatalyzed scale upof the CHPS pro-gram in the UpperEast Region.



additional modifications to improve the CHPSprogram. For example, long-term observation ofthe Navrongo project showed that neonatalmortality remained unacceptably high whilehealth among other under-five children hadimproved dramatically.29,44 The CHPS approach,as it was originally developed, lacked sufficientfocus on ways to prevent maternal and neonataldeath and disability.45 To address this, UERregional and district health managers haveinvested in a program of in-service trainingdesigned to expand the range of services CHOsprovide, with particular focus on improving andsaving newborn lives, referral services, and otherpriority programs inadequately addressed by theinitial Navrongo model.

Community Engagement and Grassroots PoliticalAction to Mobilize ResourcesThe Navrongo project uncovered the need todevelop health posts in which nurses couldlive and provide care to the community, which

would establish a balance between communityengagement and social distance. While thecommunities preferred nurses who were familiarwith local languages and customs, they wantedthe nurses to be socially removed from their ownnetworks and extended families—someone theproject termed as a ‘‘trusted outsider,’’ or aperson who would keep secrets about familyplanning and avoid favoritism that might ariseif the nurse was too closely linked to kindredgroups.

To bypass GHS restrictions on spendingresources for construction of new facilities, theUER Regional Health Administration encouragedcommunities to develop interim facilities withlocal labor, donated materials, and traditionalconstruction methods. Then managersapproached district assemblymen and develop-ment officers to replace functioning interimfacilities with more permanent structures. Adecade of systematic problem solving withcommunity engagement has been the single

TABLE 1 (continued).


Inappropriate

CHOdeployment

N Insufficient programmaticfocus on household services;health posts are the mainservice point.

N The National Health InsuranceScheme (NHIS) incentivized sta-tic services at the expense ofdoorstep care, reducing access.

N NHIS reimbursement for theprovision of clinical servicesde-emphasizes supervisoryoutreach.

N Developed supervisorywork routines that areindependent of NHISreimbursement rules

N Systems approach to CHO deploy-ment, monitoring, and supervision.Programs that focus narrowly on asingle community health workercadre, health problem, or functionare risky. ‘‘Learning localities’’ areneeded where systems functioning iscomprehensively monitored andwhere lessons learned are commu-nicated to senior officials.

N Compatibility of reimbursementschemes with doorstep care.National Health Insurance schemesrequire careful trial of their impact onnon-clinic based community-basedservice operations.

Inappropriatevolunteerdeployment

N Volunteers providing anti-pyretics can inadvertentlydelay parental health-seekingbehavior, elevating risk. Withcareful training and supervi-sion, however, volunteers canprovide integrated manage-ment of childhood illness(IMCI).

N Training volunteers insocial engagementmethods is essential.

N Female health volunteersare more committed toservice activities than malevolunteers, but male volun-teers are critical to familyplanning promotion.

N Risk mitigation with field research:Reliance on untested imported initia-tives is risky.

N Partial IMCI does not work:Volunteer services can cause moreharm than good unless volunteerdeployment is coordinated withdeployment of trained nurses andgoverned by rigorous supervision.

Communityengagement hasbeen the singlemost importantfactor in scaling upthe CHPS programin the Upper EastRegion.



TABLE 2. CHPS Scaling-Up Constraints and Responses in the Upper East Region (UER) Related to Support of DistrictHealth Systems


Information Systems

Cumbersomeinformationsystems

N Unwieldy Health ManagementInformation Systems (HMIS)require more staff time fordata management than isavailable for service delivery.

N Simplified registers from27 to 5

N Developed monitoring toolsfor outreach and supervisorysupport

N Inappropriate information systemscan impede worker commitment toscaling up.

Lack ofinformationutilization

N Lack of feedback or systemsfor information utilization

N Developed simple-to-imple-ment data visualization tools

N Implementation and supervisorysupport information is neglected inHMIS design.

Lack ofessentialinformation

N Absence of actionable infor-mation about perinatal risksand causes of death

N Developed maternal andneonatal mortality auditscheme with weekly medicalreview of results

N Training and staff developmentrequire tools for evidence-basedplanning.

Essential Equipment, Supplies, and Facilities

Shortage ofcommunity-based healthfacilities

N High cost and slow pace ofhealth post construction

N Official restrictions on the use ofGhana Health Service revenuefor construction

N Constructed interim facilitiesthrough community engage-ment and by volunteers

N Leveraged financing of con-struction through outreach todistrict political and develop-ment-sector leadership

N Community investment in construc-tion can facilitate engagement inhealth systems development.

Lack ofessentialequipment

N Shortage of motorbikes andambulances

N Lack of electrification, wells,and amenities

N Obtained support fromUNICEF and other donorsfor essential equipment,solar panels, and batteries

N Low-cost equipment can be expen-sive to maintain.

N Investment in electrification andamenities reduces worker turnoverand supports scale up.

Lack ofessentialcommodities

N Stockouts of essential drugs

N Expansion of services withoutexpansion of access to supplies

N Implemented simple stockmonitoring and logisticsreporting tool

N Total systems planning is essential toeffective community-based servicedevelopment.

Planning and Resources

Lack offinancialplanningand budgets

N Absence of a budget line forCHPS

N Implemented District HealthPlanning and ReportingToolkit (2010)

N Slow scale up can be addressed byclarifying resource managementrequirements and the health rationalefor community-based services tograssroots politicians and leaders.

Lack offlexibleresources

N Extreme constraints onresources for the CommonFund

N Cash flow delays

N Leveraged financing of theCommon Fund (3 districtsonly)

N CHPS lacks earmarked supportfrom international donors. Instead,external resources are focused ontechnical assistance. Requiring aresource-constrained system toinvest in incremental resources isunrealistic.



most important factor explaining the rapid scaleup of CHPS in the UER.

Shared and Consistent Vision and CommitmentAmong LeadersRegional and district leaders in the UER havehad a priority focus on and commitment toCHPS. From the onset, the UER HealthAdministration carried out strategies to mobilizeresources, even cutting budgets of other activitiesand temporarily curtailing services to createbudgetary space for CHPS. As UER district healthmanagers noted when they were asked aboutscaling-up problems:

Resources are not always as you need. There arealways other things that you can put in there. If thereis not that commitment to implement CHPS, youdon’t go that extra mile to put resources in place.

The response [to shortage of funding] is we justkeep going and going. Because you cannot ignorethem. You keep trying; sometimes you get lucky, inanother time you are not.

If we get to the [district] assembly and explainthings to them, [they] understand.

We discuss [CHPS] with the NGOs. We woulddraw our budget and discuss our [funding]challenge with them [and clarify] that this iswhat we want to do. But this is our challenge—tothrow more light on the program so that theywould help us.

Although launching CHPS is not expensive,its incremental costs are difficult to sustain. Theestimated total expenditure for 1 fully functionalCHPS zone covering a population of about 3,500is US$33,345 (about US$9.50/capita) (includinga solar panel but excluding CHO salaries, fuel forvehicles for monitoring activities, and trainingcosts). The most costly components are facilityconstruction ($20,240) and motorbike procure-ment ($5,300). However, if village volunteersconduct construction, using traditional materialfor building walls, the cost is reduced substan-tially (to about $3/capita). These modest costs arenonetheless a major challenge for district man-agers, who often lack adequate resources forimplementing even the most basic health serviceagenda. The incremental costs of initiating theNavrongo model was the most dominantconstraint to CHPS implementation identified

TABLE 2 (continued).


Leadership and Governance

Lack ofleadershipfor CHPS

N Absence of district andregional leadership forCHPS implementation

N Lack of facilitative supervision

N Implemented peer leadershipexchanges betweenNavrongo and district teamsand between leading districtteams and counterparts

N Implemented supervisorypeer leadership exchanges

N Leadership is developed throughtransfer of knowledge via onsitedemonstration and participatoryexchanges. Workshops are anineffective tool for leadershipdevelopment.

Failure toreplicateNavrongocommunityengagement

N Lack of community entry andengagement

N Limited focus on establishingcommunity health committees

N Absence of mechanisms fordurbars and communityexchanges

N Employed social engage-ment strategies, includingoutreach to chiefs andelders, engagement withsocial networks and opinionleaders, community durbarsfor building consensus andcollective action

N Social engagement, gender strate-gies, and traditional governancestrategies can be diluted with scaleup. Resources for exchanges,demonstration, and discussion ofsocial organizational issues can becrucial to effective scale up of com-munity health service strategies.

Absence ofpoliticalsupport

N Absence of political engage-ment strategies

N Limited district developmentinvestment in health

N Mobilized resources forhealth post constructionthrough grassroots politicalsupport

N Siloing community health develop-ment in the health sector can detractfrom scale up. Grassroots politicalengagement can contribute to off-setting resource limitations.



during the course of our interviews. Every districtdirector interviewed noted some aspect of thisproblem. For example:

There is no funding for CHPS. The strategy wasmainly to cut back on other things. It’s tough.

For me, funding is a big issue. Even when you gotDistrict Assemblies to build a compound [healthpost], really getting it functional, getting peopletrained, and getting all the logistics is the problem.

Where you want a new system to work well, youput money for it. CHPS doesn’t have [money].

When I want to [send nurses] to school I have tolook for my own funding. No one funds training.The CHOs were first supported by the districtassemblies but they say they are constrained, so theyare now funding themselves.

Everything they [District Assemblies] do dependson their common fund. If the common fund doesn’tcome, whatever they tell you, it is always difficultbecause the internally generated revenue is notadequate to even meet their overhead courses.

CHPS expansion has been most successful inareas where GHS regional and district officialshave persuaded local governments to add CHPSinto their annual budgets. Simple-to-implementcommunication strategies have facilitatedexchanges between local government authorities,politicians, and health leadership about CHPS.For example, GHS leaders have involved localofficials in CHPS-sponsored community celebra-tions of implementation progress, linking popu-lar support for CHPS to the political aspirationsof elected officials.

But not all district health directors—the localfocal points of health administration—considerCHPS as the most effective means to achievinghealth objectives, partly because most managersare unfamiliar with the Navrongo experimentbut also because many are unconvinced thatCHPS is cost-effective. To address these issues,the UER is testing a toolkit that will helpmanagers compare different budgetary optionsand their implications on offsetting health andmortality risks. This tool has provided districtmanagers with practical means of demonstratingthe potential impact of investing in CHPS onhealth outcomes and may have contributed toaccelerating the expansion of investment inCHPS between 2010 and 2012.42

In addition to their commitment to CHPS,UER leaders also shared a coherent and

consistent vision about CHPS, which contributedto the scaling-up process. According to GHSpolicy documents, CHPS is defined as ‘‘themobilization of community leadership, decision-making systems and resources in a definedcatchment area (termed a ‘zone’), the placementof reoriented frontline health staff, known asCommunity Health Officers, with logistics sup-port and community volunteer systems to pro-vide services according to the principles ofprimary health care (PHC-Plus).’’ Regional anddistrict leaders in the UER had a similarinterpretation of this policy. For example, mostUER directors considered CHPS to be functionaleven without a compound as long as CHOsprovided services. In contrast, directors basedelsewhere tended to disagree with this perspec-tive. One such manager noted:

You need a person to be there. You need acompound [health post] to make it functional.Those are the two key ingredients you need …CHPS without a compound compromises [theprogram]. At any time, people should be able tocall on you … People have been trying to definethat it’s functional without a compound. But acompound must be there. In a community, whenservices are not done holistically 24 hours, how canyou say it’s functional?

Some issues are not clear[ly] defined. What isoperational CHPS? What is functional CHPS?[We] Need to make sure that [the] document isstill relevant; [we] need to redefine to clarifyparameters. CHPS is progressing at various stages.It needs revision. People have different under-standings. People have expressed different views.Based on that, the policy should be revised.

Similarly, officers interviewed in the UERwere consistently clear about responsibilities ofthe CHOs, but CHO responsibilities were lessclearly defined elsewhere. For example, onemanager outside the UER argued that CHPSworkers should be health promoters but notservice providers:

[We] Shouldn’t overload them [the CHOs]. CHOsshould not be doing antenatal [care] and immu-nization. They should only do education … [and]should only be going out. [They] Should not besitting there.

The shared vision and commitment tothe CHPS program among UER leaders facili-tated the process of political and community

CHPS expansionwas most success-ful in areas wherelocal politicianscontributed fundsto the program’sbudget.



engagement, which in turn facilitated resourcemobilization. When health sector leadershipcatalyzes the process of community engagementand resource mobilization, CHPS scale up pro-ceeds even if no health sector revenue exists forthe program.

Peer Exchange VisitsExchange visits between new and advanceddistricts helped to facilitate scale up by givingnew CHPS program leaders an opportunity todirectly observe how the model was workingsuccessfully. Dialogue between program leadersdispelled mystery about the CHPS developmentprocess and nurtured teamwork among theimplementers. Peer exchanges were designed toachieve this by equipping visiting teams with thecapability to implement the program in 1 or 2zones.

To focus exchanges on implementation,visiting teams were encouraged to includeparticipants who could represent the contrastingimplementation responsibilities of each level ofthe system: the District Health ManagementTeam, at least 1 subdistrict supervisory team,and 2 or more CHOs from the participatingsubdistrict. These individuals were then teamedwith counterparts from an advanced implemen-tation team to plan together how to implementa functioning CHPS zone in the participatingteam’s home district.

The teams discussed the practical task ofzone implementation, community engagement,replicating exchanges between communities, andbuilding local political commitment to CHPSexpansion. Each participating team also receivedseed funds to cover the cost of implementing apilot zone, with training on how to cost andbudget the program. Taken as a set of activities,exchanges equipped and financed pilot imple-mentation of CHPS in ways that catalyzed scaleup of operations once participants returned totheir home districts.

Participants were also oriented to focus groupmethods that would enable managers to respondto community and worker opinion, adapt strate-gies to local conditions, decentralize planning,and take ownership of the program as a district-directed, scaling-up initiative.

Although 38 districts throughout Ghanaparticipated in exchanges, this process was farmore intense in the UER than elsewhere. By2004, all districts, subdistricts, and CHOs in theregion had participated in 1 or more exchanges

with the Navrongo team. National monitoringdata have since revealed that peer-exchangevisits have been more successful than work-shops. In fact, by 2008 CHPS coverage wasconcentrated in the 38 districts that participatedin exchange visits with the Navrongo orNkwanta advanced CHPS districts.15

CONCLUSION

Despite the challenges that have been identified,the CHPS initiative has begun to introducehealth care reform in every region and districtof Ghana. In the UER, where scale-up problemshave been the focus of strategic review, trial, anddissemination, CHPS has established a sustain-able service model, which ensures that progressis adapted to local realities and guided byevidence. Coverage of community-based care inthe UER was 5 times the national average after adecade of scaling up, even though the region isthe poorest in Ghana.

Nonetheless, problems with district healthsystem leadership persist and merit furtherresearch, demonstration, and policy develop-ment. The new Ghana Essential HealthIntervention Programme (GEHIP) has beenlaunched to address the evidence gap on howto improve district leadership for continuedCHPS expansion,39 including the developmentof district planning tools, resource managementsystems, and intersectoral coordination strate-gies.46 In addition, the new project is testing asimplified management information system tomeet the information needs of CHOs and districtleaders while minimizing the time and effortrequired for CHOs to capture, manage, and reportinformation.47

Although much remains to be accomplished,the CHPS experience in the UER attests to thepracticality of scaling up CHPS throughoutGhana. Its core strategy is based on the principleof putting evidence into action through research,experimentation, multiple validations, and adap-tation efforts—learning by doing.

Acknowledgments: This paper describes projects supported by grantsto the Population Council by USAID and the Finnish InternationalDevelopment Agency and grants to the Navrongo Health ResearchCentre by the Rockefeller Foundation. Writing and research on thedeterminants of CHPS scale up is part of the baseline qualitativeresearch of the Ghana Essential Health Interventions Programme(GEHIP). GEHIP is a Columbia University collaboration with theGhana Health Service, funded by the Doris Duke CharitableFoundation’s Africa Health Initiative.

Competing Interests: None declared



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______________________________________________________________________Peer Reviewed

Received: 26 November 2012; Accepted: 08 January 2013; First published online: 21 March 2013

Cite this article as: Awoonor-Williams et al. Lessons learned from scaling up a community-based health program in the Upper East Region of northernGhana. 2013;1(1):1-17. http://dx.doi.org/10.9745/GHSP-D-12-00012

� Awoonor-Williams et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permitsunrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of thelicense, visit http://creativecommons.org/licenses/by/3.0/______________________________________________________________________



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