Ghana Essential Health Intervention Project
Tuesday, May 13, 2014
Since the United Nations established the eight Millennium Development Goals (MDGs) in 2000 to galvanize global leaders around problems affecting the world’s poorest, many developing countries have seen significant increases in health funding and initiatives. While this is welcome news, most of these large-scale health programs limit their focus to specific diseases and fail to take into account the larger and oft ill-equipped systems that are essential to making lasting progress. It is with this understanding that the team behind the Ghana Essential Health Intervention Project(GEHIP), which is supported by a grant from the Doris Duke Charitable Foundation’s African Health Initiative, chose a community-based service delivery model—and the results thus far are telling. Today, the Upper East Region of Ghana, where the project is located, is one of the few places in sub-Saharan Africa on track to significantly reduce child mortality and improve maternal health—MDGs 4 and 5—by 2015.
Through a partnership between investigators at the Ghana Ministry of Health, the Ghana Health Service, the University of Ghana’s School of Public Health, Columbia University’s Mailman School of Public Health and the Navrongo Health Research Centre, GEHIP aims to improve population health by strengthening the pillars of the health system1 across district and community levels.
“Health is not just about structures,” says Ayaga A. Bawah, Ph.D., who is GEHIP’s director of research, an assistant professor at the Mailman School of Public Health and a visiting scholar at the University of Ghana’s School of Public Health. “You can build hospitals, and then nobody goes there. Or you can build a hospital and not have the manpower to run the hospital properly. So, you need to think about the health delivery system from the perspective of a systems approach: various components that coalesce to have an impact on the overall performance of the system.”
Most of GEHIP’s core elements draw from the Ghana Ministry of Health’s previous Community-based Health Planning and Services (CHPS) model, an approach tested and proven by the Navrongo Experiment in the 1990s to deliver high-quality health services in rural areas of Ghana. (While CHPS’s design was determined effective, insufficient funding and resources eroded successful implementation over time.) Like CHPS, GEHIP uses the community-based health service delivery model, which relies on trained nurses known as community health officers. These nurses deliver door-step services at patients’ homes with the support of community volunteers. In order to supplement primary-care delivery and community engagement, GEHIP has strengthened the CHPS model to include leadership development, tools for improved budget and finance planning, resources to strengthen the emergency referral process and data-driven decision-making at all levels of the health system.
“When you put things at a community level. it becomes more interactive,” says John Koku Awoonor-Williams, M.D., M.P.H., one of GEHIP’s principal investigators, a senior lecturer at the Mailman School of Public Health and presiding regional health director of the Upper East Region. “When you pull nurses from clinic situations and put them in the community, they are in situations where they are interacting with community members. They have communities that are taking part in some decision making. The nurses live with the people, so they understand the culture, the behavior—things that are driving the health in the community. You get better results.”
Because a key challenge of this community-level approach is bringing it to scale, capacity building is a major component of GEHIP. This capacity building starts with an emphasis on preparation and training at the grassroots, but extends to staff at all levels of the system. Under the project, skills of community health officers and volunteers have grown to incorporate emergency obstetric care and integrated management of childhood illness (IMCI). Training promotes facility-based delivery, post-delivery follow-up, neonatal care and emergency delivery referral. Emergency transportation better suited for the difficult terrain has been introduced into the districts with the use of inexpensive, locally sourced tri-cars that transport mothers to health facilities for critical care. To further address the needs of community health officers, GEHIP has designed a simplified information management system which supports routine service delivery.
On a larger scale, GEHIP uses technology to streamline administrative, planning and research processes. Through collaboration with the Ifakara Health Institute in Tanzania, the Policy, Planning, Monitoring and Evaluation Division of the Ghana Health Service has adapted a budgeting and planning tool from Tanzania to develop the District Health Planning and Reporting Toolkit (DiHPART). The toolkit allows district management teams to advocate for investment in appropriate interventions and facilitate the allocation of flexible funds. Leadership development and managerial training necessary for DiHPART implementation has directly improved budgeting and planning for district health activities.
The project also uses DiHPART and the Geographic Information Systems (GIS) to improve the capability of health leaders to advocate for essential resources. DiHPART, for example, has proven a valuable instrument for demonstrating the importance of district investment in CHPS, identifying resource gaps and drawing in revenue for the health sector. Furthermore, GIS mapping has been useful in influencing politicians’ decision-making regarding the placement of health clinics, public health services and potable wells. This mapping has not only helped expedite the introduction of facilities to isolated communities, but also to map disease outbreaks and inform targeted health initiatives.
The GEHIP team is implementing this multi-faceted intervention in the Upper East Region, an area of Ghana that comprises the three poorest districts in the country—Garu-Tempane, Bongo and Builsa. These districts contain a target a population of more than 300,000 people.
The challenges this region faces are many. Dr. Awoonor-Williams says that 11 doctors serve a population of 1.1 million and that this lack of human resources—compounded by poor infrastructure and inclement weather—can make transportation to health facilities nearly impossible. If individuals are able to reach health facilities, necessary supplies such as medications are not always available. In addition, clinicians do not have access to efficient information systems for recording patient treatments and guiding future health care decisions. Obstacles that community members and health service providers regularly encounter are at times unmet by politicians, some of whom use economic and political interests to dictate the location of necessary health clinics and services.
“There was never any question that we were going to base this in the most difficult location in the country,” says James F. Phillips, Ph.D., co-principal investigator and a professor at Columbia University’s Mailman School of Public Health. “We weren’t going to put this in offices in Accra or New York. The team and our offices would be located where the problem was located. And we were going to implement the project on a scale that was meaningful to the Ghana Health Service. We were going to build a system that could be replicated eventually and understood as being relevant to the national scheme.”
GEHIP has worked to mitigate the various challenges that communities and clinicians face in the Upper East Region, and has generated positive results in the first five years of the six-year project. The project achieved universal health coverage via CHPS in the three implementation districts, increasing health service delivery from an initial rate of 20% in 2009 to 100% by the end of 2013. And despite being the poorest region in Ghana, the Upper East Region is among the few regions on course to achieve MDG4 by 2015.
Notably, the program has successfully integrated research and policy to allow for continuous adoption of evidence-based interventions. In the past, research and service delivery have been separate. GEHIP exists as an important approach in which evaluation takes place alongside implementation. Moreover, unlike many projects planned by external research institutes, the program is designed and implemented by agents of the health system.
“This is the first time that we have a project which is situated in and being run by the Ghana Health Service and the Ministry, itself. For us that is a strength,” says Awoonor-Williams. Due to this unique position, implementation strategies of GEHIP have a likelihood of being translated directly into national policy.
Now that GEHIP has shown signs of success in its implementation districts, the project’s researchers and practitioners continue to think critically about how to prompt national scale-up.
“We are looking at ways in which we can look beyond this project: What is the next thing that we should do? How do we take this to scale? How do we get this to other places where they can draw lessons from the work that we have done?” says Bawah. “We are thinking about sustainability.”
1 The World Health Organization defines the six building blocks of health systems as service delivery, health workforce, information, medicines, financing and governance.