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

Introduction

As the world strives to achieve Universal Health Coverage and the Sustainable Development Goals, primary healthcare is foundational to meeting these goals^1,2. Community healthcare systems serve critical roles within strong primary healthcare delivery^2–4. The World Health Organization’s recent guidelines⁵ for best practices of community health workers (CHWs) offer important guidance to policy makers and program implementers about how to develop strong community health service delivery and support low- and middle-income countries along the path towards universal health coverage. Among other key recommendations, these guidelines highlight the importance of professionally-trained CHWs with clear roles and responsibilities, supported by strong supervision systems to ensure quality service delivery⁵.

Ghana has a strong history of high-quality community-based primary healthcare delivery, including the development of the Community-based Health Planning and Services (CHPS) in 1994⁶, with significant expansion and strengthening of those services over the past 25 years. In recent years, the Ghana Health Service has developed a set of 15 steps and six milestones to guide CHPS implementation across the country^7,8. CHPS service delivery is based on the deployment of Community Health Officers (CHOs) throughout the country in CHPS zones. These CHOs work closely with the Community Health Volunteers (CHVs), who are responsible for home visits, community mobilizations, participation in health outreach services with the CHOs, and household health education⁸. More detailed descriptions of the roles and responsibilities of CHOs and CHVs are provided in Table 1 and Table 2.

In 2014, in conjunction with the global One Million Community Health Workers Campaign, the government of Ghana formally launched the National CHW Program, with the goal of expanding high-quality community health services throughout the country⁹. This program was designed to augment the pre-existing CHPS work. While the deployment of CHOs and CHVs had been a positive step to date, their capacity was inadequate to provide the optimal level of community-based care that the government aspired to, especially in rural areas where higher-level facility-based care was not easily accessible to much of the population⁹.

In order to address these challenges, a new cadre of health worker, the CHW, was introduced in the National CHW Program⁹. According to the program design, these CHWs report directly to the CHOs, and provide first-level health care throughout the communities. Detailed descriptions of the CHW roles and responsibilities are included in Table 3.

CHWs are expected to spend 80% of their time in the community, providing these services via household visits. To ensure the quality of their work, CHWs are expected to meet with their CHO supervisors at least quarterly and also interface with the CHVs during the course of their work, especially in the context of organizing community health-related gatherings and educational campaigns^8,9.

While the policies for training, supervision, and the responsibilities of CHWs are clearly delineated⁹, there is a paucity of data describing the current state of CHW service scale-up across the country, including how the CHWs’ work relates to the work of the CHOs and CHVs. Given the extensive efforts that have gone into strengthening community-based health services in Ghana, understanding the present status of CHW services is important for policy makers and program implementers to target improvement initiatives for the future.

Here, we present data describing the supervision and activities provided by CHWs throughout the country. These data were collected from the facility surveys done as part of the 2017 round of the Performance Monitoring and Accountability 2020 (PMA2020) national survey¹⁰.

Methods

Results

In 2017, 151 healthcare facilities were surveyed and of those, 86 (57%) facilities reported supporting CHWs. The 86 CHW-supporting facilities were distributed across all 10 regions in Ghana and included a mix of hospitals (33.7%), health centers (39.5%), and CHPS facilities (26.7%) (Table 4).

Nationally, there were more CHWs supervised on a per-facility basis at the hospital and health center levels than the CHPS facilities (median number of CHWs per facility: 20, 10, and 4, respectively) (Table 2). Most CHWs were supervised by CHOs at health centers and CHPS facilities (74% and 78%, respectively), while hospital-based CHW supervision was managed by both CHOs (38%) and Public Health Nurses (62%) (Table 5).

Nationally, there was considerable variability in the frequency of supervision interactions between CHWs and their supervisors, and these data show that the majority (55.8%) of CHWs interacted with their supervisors approximately once per month (Table 6). An additional 25.6% of CHWs interacted with their supervisors more than once per month, meaning than over 80% of CHWs described in these data had at least monthly supervision interactions (Table 6). The frequency of interactions did not seem to vary substantially by facility or supervisor type. CHWs based at hospitals, health centers, and CHPS all interacted with their supervisors at approximately the same frequency (median number of days between interactions: 30, 30, and 30, respectively) (Table 7). The frequency of supervision interactions did not differ between types of supervisors (public health nurses, CHOs, midwives), with a median of 30 days between interactions for all supervisor types, except for the single Health Assistant supervisor included in the sample (7 days) (Table 7).

There was wide variability in the types of services delivered by CHWs, by both facility type and region, as described in Table 8 and Table 9. Of the activities that are expected to be delivered by CHWs according to the National CHW Program policies⁹, some services, such as community mobilization, health education, and outreach for loss-to-follow-up, were delivered by over three-quarters of all CHWs (Table 8). In contrast, other services, such as mental health counseling and postnatal care were much less common, being delivered by less than one third of CHWs nationally. Notably, while not included in the expected scope of work by national guidelines, 22.4% of CHWs were reported to be providing non-communicable disease treatment services. Regionally, there was great variation in service delivery, with some services, such as active case finding or immunizations, being delivered by all CHWs in one region but not delivered by any CHWs in other regions (Table 9).

Discussion

In Ghana, where there is a long-standing commitment to quality community-based primary healthcare, the 2014 National CHW program was designed to strengthen the pre-existing community-based service provision. To date, however, there is scant data to understand the success of the program implementation. We have presented data that show variability in both supervision and the CHW activities provided across the country. The details of these data offer several important insights to program implementers and policy makers for the future of strong community-based primary healthcare services in Ghana.

The variability in the frequency of supervision interactions between CHWs and their supervisors is notable, in light of national⁹ and global^5,12 guidelines that aspire to consistent, frequent supervision systems for CHWs to ensure quality service delivery. The variability seems to be agnostic of facility type or supervisor type, and over 80% of the CHWs described here were reported to be interacting with their supervisors at least monthly, which is much more frequently than the quarterly goals set forth in the National CHW Program guidelines⁹. While more frequent supervision is likely beneficial, this reported variability in frequency of interactions offers a clear area for standardization throughout the program. Additionally, even amongst the CHW-supervisor pairs that are meeting national goals, it would be informative to investigate the ideal frequency of supervision in order to optimize limited resources.

Our data show considerable variability in the type of activities performed by the CHWs, and the degree of availability of each activity, across the different regions of the country. While this survey inquired about only a sample of the expected services included in the national guidelines⁹, it is clear that many expected activities are not yet being provided by CHWs, or only minimally provided in certain regions. Only three activities – community mobilization, health education, and outreach for loss to follow-up patients – were reported to be provided by the CHWs affiliated with more than three-quarters of surveyed facilities nationally, and even these were not universally available throughout all regions. Multiple other services that are included in the national guidelines, including antenatal care (ANC) counseling, community-based integrated management of childhood illness, immunization services, mental health counselling, and post-natal care, were reported to be provided by less than half of CHWs nationally, and far fewer in some regions.

At the regional level, we also found variability in service provision, with some regions’ facilities reporting much higher provision of CHW activities than others. In particular, the Western region reported especially low rates of CHW services provided, with all activities except family planning provision (88.9%) being provided by CHWs affiliated with less than half the facilities, and six expected activities being provided by no facility at all. The Greater Accra region also had lower provision rates of many activities, which may be related to differential implementation of the CHW program within the larger urban area, where services might be provided by other actors and facility types, unlike the more remote areas.

Our data show evidence of an expanded role for CHWs, beyond that specified in the national guidelines. All regions except the Greater Accra region reported CHW provision of non-communicable disease treatment. While these data only describe what the facility managers reported, and thus cannot provide insights into the details of these non-communicable disease services, nor the technical quality of their provision, this is an important finding. Given that these are not included in the national CHW guidelines, this demonstrates that there is at least some implementation of novel service delivery throughout the country. Some of these activities may be provided in the context of local pilot programs or community-based programs, although our survey data are not specific enough to elucidate those details. Regardless, given that non-communicable diseases are priorities for the national health sector⁸, this finding warrants further investigation to better understand the feasibility of CHWs providing these services at a high level of quality, and planning for potential inclusion in the national program in a more standardized manner.

Our data have several important limitations. First, they are descriptive data only, which were collected in the process of the PMA2020 survey, which is not explicitly designed to study CHW activities. Thus, their level of detail is limited, and further investigation is required to better characterize and understand the aforementioned findings. Second, these data are from facility manager reports, who may have limitations in their knowledge, which may impact the quality and accuracy of these data. Third, given that the methodology of the PMA2020 sampling strategy is not designed around CHW staffing, the collected data may not be optimal in all regions of Ghana. Finally, our survey inquired very specifically about “community health workers” during each facility survey, but given the multiple cadres involved in community health-related services throughout the country (including, for example, CHOs and CHVs), it is plausible that some survey respondents may have provided answers that were not exclusively about the CHWs affiliated with their facility. Thus, our data may represent information about other community health-related cadres in Ghana. Further research and program planning should include survey methods to more explicitly differentiate CHWs from the other cadres, to ensure that the correct conclusions are attributed to the appropriate cohort of health workers

Conclusions

We have presented descriptive data summarizing the current status of CHW supervision and activities in Ghana. These data provide policy makers and program implementers helpful insights to inform targeted improvement initiatives throughout the country. Furthermore, these data can help to better inform ongoing monitoring and evaluation strategies of community health programming in Ghana. Other countries that utilize the PMA2020 survey methodology, or comparable survey methods, may consider using similar survey techniques, as described here, to better understand their national community health programming.

Data availability