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primary health care, community health workers, universal health coverage, Ghana, CHPS
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Schwarz D, Kim JH, Ratcliffe HL et al. The status of Ghanaian community health workers’ supervision and service delivery: descriptive analyses from the 2017 Performance Monitoring and Accountability 2020 survey [version 3; peer review: 2 approved]. Gates Open Res 2019, 3:1468 (https://doi.org/10.12688/gatesopenres.12979.3)
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Research Note
Revised
The status of Ghanaian community health workers’ supervision and service delivery: descriptive analyses from the 2017 Performance Monitoring and Accountability 2020 survey
[version 3; peer review: 2 approved]
PUBLISHED 23 Aug 2019
Abstract
Corresponding author:
Dan Schwarz
Competing interests:
No competing interests were disclosed.
Grant information:
This work was supported by the Bill and Melinda Gates Foundation [OPP1149078].
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Copyright:
© 2019 Schwarz D et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Schwarz D, Kim JH, Ratcliffe HL et al. The status of Ghanaian community health workers’ supervision and service delivery: descriptive analyses from the 2017 Performance Monitoring and Accountability 2020 survey [version 3; peer review: 2 approved]. Gates Open Res 2019, 3:1468 (https://doi.org/10.12688/gatesopenres.12979.3)
First published: 20 May 2019, 3:1468 (https://doi.org/10.12688/gatesopenres.12979.1)
Latest published: 23 Aug 2019, 3:1468 (https://doi.org/10.12688/gatesopenres.12979.3)
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Revised Amendments from Version 2
We are grateful to the Dr. Ballard and Dr. Perry for their insightful peer-review comments. In this updated version, in response to their feedback, we have provided additional details regarding the community health worker training and salary structures; contextualized the community health officers as a type of community health worker; provided more detailed discussion about the supervision of community health workers at hospitals; discussed the implications of the 2016 guidelines in greater detail; included additional citations for some of the contextual data regarding the community health worker program in Ghana; and added to the limitations section describing survey biases in more detail. We have also included some clarifying text regarding the 2014 launch of the National 1 Million CHW program, which is distinct from other prior community health-related programs. Finally, we have corrected several prior typographical and grammatical errors.
No data, analyses, or figures have been added or changed. No changes have been made to authorship. We have no competing interests in regards to these updated changes, nor to the original content of the manuscript.
See the authors' detailed response to the review by Madeleine Ballard
See the authors' detailed response to the review by Henry B Perry
Introduction
As the world strives to achieve Universal Health Coverage and the Sustainable Development Goals, primary healthcare is foundational to meeting these goals1,2. Community healthcare systems serve critical roles within strong primary healthcare delivery2–4. 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 country7,8. CHPS service delivery is based on the deployment of Community Health Officers (CHOs) throughout the country in CHPS zones. These CHOs – a type of community health worker in and of themselves9 -- 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.
Table 1. Roles and responsibilities of Community Health Officers (CHOs)8.
CHV, community health volunteer; CHMC, community health management committee; CHAP, community health action plan; BF, breast feeding; ARI, acute respiratory infection; STI, sexually transmitted infection; ANC, antenatal care; PNC, postnatal care; PMTCT, prevention of mother-to-child transmission; TB, tuberculosis; NTD, neglected tropical disease; FP, family planning; NHIS, National Health Insurance Scheme; DHIMS, District Health Information Management System
Table 2. Roles and responsibilities of Community Health Volunteers (CHVs)8.
In 2014, in conjunction with the global One Million Community Health Workers Campaign, the government of Ghana formally launched the National 1 Million CHW Program, with the goal of expanding high-quality community health services throughout the country10. This program was designed to support the pre-existining community health programs that had been built to date10.
In order to address these challenges, a new cadre of health worker, was introduced in the National 1 Million CHW Program10. These CHWs are fully-employed workers, with a salary of approximately $142 USD per month, under the auspices of the Youth Employment Agency10. According to the program design, these CHWs report directly to the CHOs, supporting them to provide first-level health care throughout the communities. Detailed descriptions of the CHW roles and responsibilities are included in Table 3. The program set a goal of deploying over 31,000 CHWs throughout the country between 2014 and 202310. By the end of 2019, the goal is to have achieved full rural coverage of the CHW program, involving approximately 28,000 CHWs. As of July 2019, approximately 26,000 have been trained and deployed, the distribution of which can be viewed on the program’s online data dashboard11 and coverage map12.
Table 3. Roles and responsibilities of Community Health Workers (CHWs)10.
ART, antiretroviral therapy; TB, tuberculosis; SDHT, sub-district health team; ORS, oral rehydration salt; MUAC, mid-upper arm circumference; LLIN, long-lasting insecticidal nets; ACT, artemisinin-based combination therapy; RDT, rapid diagnostic test; EBF, exclusive breast feeding; ANC, antenatal care; STD, sexually transmitted disease; TBA, traditional birth attendants; CHV, community health volunteer.
CHWs are expected to spend 80% of their time in the community, providing these services via household visits. Per the program guidelines, the CHWs are intended to support the CHPS work, and are not supposed to be specifically attached to any hospitals8,10. In practice however, after the program’s initiation in 2014, anecdotal evidence suggests that many CHWs have been functionally reporting to, or interacting with, facility managers at hospitals.
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 campaigns8,10.
While the policies for training, supervision, and the responsibilities of CHWs are clearly delineated10 -- including twenty-eight weeks of pre-service training and one week update training twice yearly -- 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 survey13. Given the anecdotal evidence that some CHWs were directly interacting with hospital-level facilities, the survey asked these questions at all facility types, to best characterize the landscape of CHW work nationally.
Methods
Survey
The PMA2020 survey is a nationally representative, rapid-turnaround cross-sectional survey of family planning indicators among women of reproductive age (ages 15–49), and water, sanitation, and hygiene indicators among households, in 10 countries13. Using a two-stage cluster design, households were selected to estimate the national modern contraceptive prevalence rate within 3%. In order to better understand access to family planning and primary health care in these countries, data were also collected on health care facilities where women received care. The methods used to collect data from health facilities in the PMA2020 survey have been described in detail elsewhere13. Briefly, health care facilities in each enumeration area were surveyed by trained enumerators, who used mobile data collection technology to interview the heads of facilities and upload the data into a secure cloud server. Data is uploaded as direct responses to the survey tool, as described elsewhere13. We analyzed the PMA2020 survey data collected in Ghana from September 2017 to November 2017 in the 100 enumeration areas surveyed throughout the country14.
In each enumeration area, a census of the public health facilities that serve the enumeration area was conducted to populate the list of survey facilities. Since the survey focused on the primary level of care, the district hospital that serves as the referral facility for all the surveyed facilities was also studied. Facilities of different sizes and levels, from CHPS facilities to health centers and hospitals, were selected to be included in the overall PMA2020 survey sample with the intent to represent the variety of available health facilities in each enumeration area, which are utilized by the nationally representative sample of women of reproductive age.
We explored several aspects of CHW service delivery in Ghana. The PMA2020 survey collected data on whether facilities supported CHWs with supervision and/or supplies (yes/no), what type of facility was reporting CHW data (CHPS/health center/hospital), who at the facilities supervised the CHW (community health officer/public health nurse/midwife/health assistant/physician assistant), and how frequently the CHW was supervised. Frequency of supervision was categorized as days between supervision interactions. If “monthly” was reported, that was categorized numerically as every 30 days.
We also investigated the different types of activities CHWs were involved in, and how these varied by facility type and region. Supervisors were asked about activities and services offered by CHWs from their facility, in reference to CHW activities as defined in the National 1 Million CHW Program documentation10. While not included in the expected scopes of work for CHWs, we also investigated non-communicable disease treatment as a key priority area for potential future service expansion8,10. All data analyzed had been collected as part of the PMA2020 survey, using the methods previously described.
Data analyses
Analyses were conducted using descriptive statistics and figures to report on facility-reported supervision and activities of CHWs within the survey. To assess central tendencies and distributions of CHWs and how frequently they were supervised across different facility types we calculated medians, standard deviations (SD), and interquartile ranges (IQRs) by each facility type. We also calculated counts and percentages to determine who supervised CHWs at each facility type, as well as how frequently they were supervised by each facility and supervisor type. Finally, we examined the types of activities CHWs were performing by examining counts and percentages of each activity by facility type and region and created a heat map based on frequency of each activity. As the purpose of this study was descriptive rather than inferential, no null hypothesis testing was conducted. Any missing data are noted in the data tables. No imputation was done for the purposes of this study. Analyses were performed using Stata 15.1 (StataCorp, College Station, TX).
Ethical statement
This study was approved by the ethical review boards at the School of Medical Sciences / Komfo Anokye Teaching Hospital Committee on Human Research Publications and Ethics (Kumasi, Ghana; protocol CHRPE/AP/740/1.3), Johns Hopkins University (Baltimore, USA; protocol 7238), and Brigham and Women’s Hospital (Boston, USA; protocol 2016P002284). All study participants provided informed, written consent.
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).
Table 4. Regional distribution of facilities supporting community health workers (CHWs) included in the PMA2020 survey.
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).
Table 5. Characteristics of community health worker (CHW) distribution and supervision by facility type.
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).
Table 6. Frequency of community health worker (CHW) supervision interactions.
| Days between interactions | Number | Percent |
|---|---|---|
| Daily | 5 | 5.8 |
| 3 | 1 | 1.2 |
| 7 | 14 | 16.3 |
| 14 | 2 | 2.3 |
| 30 | 48 | 55.8 |
| 60 | 4 | 4.7 |
| 90 | 6 | 7.0 |
| 120 | 6 | 7.0 |
| Total | 86 | 100.0 |
Table 7. Frequency of community health worker (CHW) supervision interactions by facility and supervisor types.
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 1 Million CHW Program policies10, 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).
Table 8. Community health worker (CHW) activities by facility type.
| CHW activity | Overall* | Hospitals | Health centers & clinics | CHPS | ||||
|---|---|---|---|---|---|---|---|---|
| No. | % | No. | % | No. | % | No. | % | |
| Community mobilization | 75 | 88.2 | 24 | 82.8 | 33 | 97.1 | 18 | 81.8 |
| Health education | 67 | 78.8 | 22 | 75.9 | 31 | 91.2 | 14 | 63.6 |
| Outreach for loss to follow-up | 65 | 76.5 | 21 | 72.4 | 29 | 85.3 | 15 | 68.2 |
| Disease surveillance | 61 | 71.8 | 19 | 65.5 | 27 | 79.4 | 15 | 68.2 |
| WASH counseling | 58 | 68.2 | 18 | 62.1 | 26 | 76.5 | 14 | 63.6 |
| Enrollment in facility | 56 | 65.9 | 20 | 69.0 | 26 | 76.5 | 10 | 45.5 |
| Active case finding | 54 | 63.5 | 17 | 58.6 | 24 | 70.6 | 13 | 59.1 |
| FP counseling | 47 | 55.3 | 14 | 48.3 | 24 | 70.6 | 9 | 40.9 |
| FP Provision | 45 | 52.9 | 12 | 41.4 | 21 | 61.8 | 12 | 54.5 |
| ANC counseling | 42 | 49.4 | 13 | 44.8 | 21 | 61.8 | 8 | 36.4 |
| C-IMCI-iCCM | 35 | 41.2 | 7 | 24.1 | 20 | 58.8 | 8 | 36.4 |
| Immunization | 34 | 40.0 | 15 | 51.7 | 12 | 35.3 | 7 | 31.8 |
| Directly observed therapy for TB | 32 | 37.6 | 11 | 37.9 | 16 | 47.1 | 5 | 22.7 |
| Mental Health Counseling | 25 | 29.4 | 9 | 31.0 | 12 | 35.3 | 4 | 18.2 |
| Postnatal care | 19 | 22.4 | 6 | 20.7 | 11 | 32.4 | 2 | 9.1 |
| Non-communicable disease treatment^ | 19 | 22.4 | 6 | 20.7 | 10 | 29.4 | 3 | 13.6 |
* Data missing on one facility. ^Not included in the national CHW guidelines. CHPS, Community-based Health Planning and Services; FP, family planning; TB, tuberculosis; ANC, antenatal care; C-IMCI-iCCM, Community Integrated Management of Childhood Illnesses – Integrated Community Case Management; WASH, water, sanitation and hygiene.
Table 9. Community health worker (CHW) activities by region.
| Overall* | Ashanti | Brong Ahafo | Central | Eastern | Greater Accra | Northern | Upper East | Upper West | Volta | Western | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No. | % | No. | % | No. | % | No. | % | No. | % | No. | % | No. | % | No. | % | No. | % | No. | % | No. | % | |
| Community mobilization | 75 | 88.2 | 15 | 100 | 7 | 77.8 | 10 | 100 | 11 | 91.7 | 8 | 88.9 | 3 | 100 | 6 | 100 | 4 | 100 | 7 | 87.5 | 4 | 44.4 |
| Health education | 67 | 78.8 | 11 | 73.3 | 8 | 88.9 | 10 | 100 | 9 | 75 | 5 | 55.6 | 2 | 66.7 | 6 | 100 | 4 | 100 | 8 | 100 | 4 | 44.4 |
| Outreach for loss to follow-up | 65 | 76.5 | 10 | 66.7 | 6 | 66.7 | 10 | 100 | 11 | 91.7 | 7 | 77.8 | 3 | 100 | 6 | 100 | 4 | 100 | 7 | 87.5 | 1 | 11.1 |
| Disease surveillance | 61 | 71.8 | 13 | 86.7 | 8 | 88.9 | 7 | 70 | 10 | 83.3 | 6 | 66.7 | 2 | 66.7 | 6 | 100 | 4 | 100 | 5 | 62.5 | 0 | 0 |
| WASH counseling | 58 | 68.2 | 9 | 60 | 7 | 77.8 | 10 | 100 | 10 | 83.3 | 4 | 44.4 | 3 | 100 | 4 | 66.7 | 3 | 75 | 6 | 75 | 2 | 22.2 |
| Enrollment in facility | 56 | 65.9 | 8 | 53.3 | 7 | 77.8 | 7 | 70 | 8 | 66.7 | 6 | 66.7 | 3 | 100 | 6 | 100 | 3 | 75 | 8 | 100 | 0 | 0 |
| Active case finding | 54 | 63.5 | 12 | 80 | 8 | 88.9 | 4 | 40 | 8 | 66.7 | 6 | 66.7 | 2 | 66.7 | 5 | 83.3 | 4 | 100 | 5 | 62.5 | 0 | 0 |
| FP counseling | 47 | 55.3 | 8 | 53.3 | 3 | 33.3 | 8 | 80 | 8 | 66.7 | 1 | 11.1 | 3 | 100 | 3 | 50 | 3 | 75 | 7 | 87.5 | 3 | 33.3 |
| FP Provision | 45 | 52.9 | 4 | 26.7 | 4 | 44.4 | 8 | 80 | 6 | 50 | 1 | 11.1 | 3 | 100 | 1 | 16.7 | 3 | 75 | 7 | 87.5 | 8 | 88.9 |
| ANC counseling | 42 | 49.4 | 7 | 46.7 | 4 | 44.4 | 6 | 60 | 6 | 50 | 1 | 11.1 | 3 | 100 | 5 | 83.3 | 3 | 75 | 6 | 75 | 1 | 11.1 |
| c-IMCI-iCCM | 35 | 41.2 | 7 | 46.7 | 3 | 33.3 | 4 | 40 | 8 | 66.7 | 1 | 11.1 | 2 | 66.7 | 3 | 50 | 2 | 50 | 5 | 62.5 | 0 | 0 |
| Immunization | 34 | 40 | 6 | 40 | 3 | 33.3 | 2 | 20 | 2 | 16.7 | 9 | 100 | 0 | 0 | 1 | 16.7 | 1 | 25 | 6 | 75 | 4 | 44.4 |
| Directly observed therapy for TB | 32 | 37.6 | 7 | 46.7 | 4 | 44.4 | 2 | 20 | 8 | 66.7 | 2 | 22.2 | 1 | 33.3 | 2 | 33.3 | 1 | 25 | 5 | 62.5 | 0 | 0 |
| Mental Health Counseling | 25 | 29.4 | 4 | 26.7 | 1 | 11.1 | 6 | 60 | 5 | 41.7 | 0 | 0 | 1 | 33.3 | 1 | 16.7 | 2 | 50 | 5 | 62.5 | 0 | 0 |
| Postnatal Care | 19 | 22.4 | 4 | 26.7 | 2 | 22.2 | 3 | 30 | 2 | 16.7 | 0 | 0 | 0 | 0 | 2 | 33.3 | 1 | 25 | 5 | 62.5 | 0 | 0 |
| Non-communicable diseases^ | 19 | 22.4 | 3 | 20 | 1 | 11.1 | 3 | 30 | 4 | 33.3 | 0 | 0 | 1 | 33.3 | 2 | 33.3 | 1 | 25 | 3 | 37.5 | 1 | 11.1 |
Discussion
In Ghana, where there is a long-standing commitment to quality community-based primary healthcare, the 2014 National 1 Million 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. Additionally, these data show very clearly that, while not designed to be posted to hospitals, hospital-supervised CHWs are common 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 national10 and global5,15 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 guidelines10. 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 guidelines10, 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.
Finally, our data show that, in eight of the ten regions, at least some CHWs are supervised by CHOs who operate from hospitals. These CHOs have been assigned CHPS zones in which they work with the CHWs, as mentioned on the data summary page12. Given that the program is intended to support the CHPS work, and that the CHWs are supposed to spend more than 80% of their time in the community, this finding has important implications for the future of the program. Notably, it is plausible that the multiple types of community health cadres, with often-times overlapping or conflicting sets of job descriptions and service delivery guidelines, may have contributed to this phenomenon of CHWs being supervised by CHOs at hospitals. The new guidelines for CHPS were released in 20168, which may help to clarify scopes of work among the different cadres supporting community health activities throughout the country.
Limitations
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. Relatedly, it is not possible for us to determine what percentage of the entire CHW population is accurately reflected in these data; there may be many CHWs who are not in frequent contact with these managers and thus not well-represented by these data. Additionally, since these data are all from facility managers, who may have their own inherent biases, it is quite possible that some of these data represent over-estimates of CHW supervision and activities.
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, and importantly do not reflect the new 16-region geographical distribution, which was expanded from the prior 10-region distribution in early 2019. The new 16-region geographical distribution can be seen on the Ghanaian Embassy site.
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 CHVs9), 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
Underlying data
All data used in this study are available via the PMA2020 website. Per the data use guidelines of the PMA2020 databases, all PMA2020 datasets are free to download and use, although users are required to register for a PMA2020 dataset account. This is to ensure that data use can be appropriately tracked by the PMA2020 database managers. The request form must include a brief description of the research or analysis that the user would like to conduct using the requested data. If the research question is not clear, the database managers of PMA2020 may follow-up for further clarification. Once users are granted access, a zipped folder with the compressed dataset, brief user notes, and survey questionnaires will be made available to the user. All data sets will be de-identified. Users can download the codebooks as well.
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Schwarz D, Kim JH, Ratcliffe HL et al. The status of Ghanaian community health workers’ supervision and service delivery: descriptive analyses from the 2017 Performance Monitoring and Accountability 2020 survey [version 3; peer review: 2 approved]. Gates Open Res 2019, 3:1468 (https://doi.org/10.12688/gatesopenres.12979.3)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Comments on this article Comments (1)
Version 3
VERSION 3
PUBLISHED 23 Aug 2019
Revised
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Reader Comment 05 Sep 2019James F. Phillips, Mailman School of Public Health, Columbia University, New York, USA05 Sep 2019Reader CommentCommentary authored by:
James F. Phillips, MS, PhD[1]
Fred N. Binka, MD, MPH, PhD[2]
Commentary on:
The status of Ghanaian community health workers’ supervision and service delivery: descriptive analyses from the 2017 Performance Monitoring ... Continue reading
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations -
A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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James F. Phillips, MS, PhD[1]
Fred N. Binka, MD, MPH, PhD[2]
Commentary on:
The status of Ghanaian community health workers’ supervision and service delivery: descriptive analyses from the 2017 Performance Monitoring ... Continue reading Commentary authored by:
James F. Phillips, MS, PhD[1]
Fred N. Binka, MD, MPH, PhD[2]
Commentary on:
The status of Ghanaian community health workers’ supervision and service delivery: descriptive analyses from the 2017 Performance Monitoring and Accountability 2020 survey
by
Dan Schwarz, June-Ho Kim, Hannah Ratcliffe, Griffith Bell, John Koku Awoonor-Williams,
Belinda Nimako, Easmon Otupiri, Stuart Lipsitz, Lisa Hirschhorn, and Asaf Bitton
Gates Open Research. 2019;3:1468. doi:10.12688/gatesopenres.12979.2
Background:
In May, 2019, Gates Open Research published an implementation scientific investigation of a program in Ghana that has assigned a new cadre of volunteer community health workers to an existing program of community-based nursing services.1 Entitled “The status of Ghanaian community health workers’ supervision and service delivery: descriptive analyses from the 2017 Performance Monitoring and Accountability 2020 survey,” the paper was a carefully prepared appraisal of the question: Is supervision associated with a new program for assigning Community Health Workers (CHW) being effectively implemented? The program in focus represents Ghana’s response to an international initiative known as the One Million Community Health Worker Campaign which aims to expand community-based primary health care coverage throughout Africa.2 Launched in 2014 in Ghana, the Campaign was intended to augment an existing program, known by the acronym, “CHPS,” for Community-based Health Planning and Services. 3–5 The CHPS program was researched in the 1990s,6–8 adopted as national policy in 1999, and launched as a national scaling-up program in 2000.9,10 When monitoring during its first decade of operation showed that CHPS was not achieving its planned expansion goals, reforms were instituted that have accelerated CHPS coverage in the second decade of CHPS operation.11 In this context of reform and action, the “One Million CHW Campaign” was also launched in 2014, with the goal of adding a cadre of semi-volunteer personnel, community services, and care to the existing CHPS agenda.2,5
The CHPS program and the CHW initiative are being undertaken in conjunction with CHW deployment policy proliferation throughout sub-Saharan Africa. 12,13 Evidence from cross-national literature reviews showing that deployment in rural settings of South Asia and sub-Saharan Africa can save lives14–18 has fostered international endorsement of the regimen of care that is known as “Integrated Management of Childhood Illness (iCCM),19,20 a core strategy for achieving universal health coverage (UHC) in resource deprived settings.21 Although the need to launch iCCM in Ghana is without question, research also attests to the need for careful primary impact appraisals wherever manpower for addressing this goal is added to an existing system of community based primary health care.22 Home visitation by CHW has been shown to have potential for mortality reducing impact among neonates,23 and iCCM, if appropriately delivered, can accelerate reductions in childhood mortality.14,15,24–26 But, evidence also shows that systems thinking is critical to CHW success,27,28 and context specific evaluation is important since integration of CHW into the broader health system is critically important,29 since systems differ markedly by country, and failure to integrate CHW into systems of work, supervision, leadership, and logistics can lead to interlocking problems and unanticipated adverse outcomes.30,31
Comments on the Schwarz et al. publication:
It is against this contextual backdrop that we direct this commentary. The Schwarz et al. paper was a carefully conducted implementation study that is nonetheless pointless. If primary research had been conducted showing that CHW deployment program saves lives or improves health when it is functioning, then the quality or intensity of supervision of its large scale operation would be of paramount importance. But, in the absence of this primary evidence, implementation research does not matter. It is possible that the package of services that CHW are deployed to provide could save lives, if the services cited by Schwarz et al. are actually provided and if these workers do so in isolation of population exposure to other components of Ghana’s primary health care system. But, there is ample reason to question whether the addition of a cadre to CHPS, as envisioned by the 1 Million CHW campaign, is sound:
Has primary research demonstrated that supplementing CHPS with CHW adds value? The CHW program was piloted as an add-on to the Millennium Village Project (MVP) in six districts of the Ashanti Region. When the MVP was replicated in study districts in the Northern and Upper East Regions, the project had only marginal effects on some health indicators, and no discernible survival impact.32 Primary impact research on CHW deployment is needed: Adding CHW to a failed MVP strategy may or may not add value to services already provided by CHPS. The survival effects of adding CHW to Ghana’s system of primary health care remains unknown.
The concept of phasing research methodologies is important in this instance. The Schwarz et al. article is an application of implementation science, a type of health systems investigation that assesses the causes, consequences and challenges associated with bringing to scale proven improvements in health technology, service quality, or changes in systems of care.33,34 Investigating the gap between innovation potential and actual system functioning can be the subject of a wide variety of types of investigations involving experiments, qualitative diagnostic research, or quantitative appraisals of system functioning. However, Holl such work is predicated on the prospect that the concept in question is, in fact, proven to have potential benefits. This requires prior completion of primary research establishing the fundamental value of changing operations according to a proven alternative to the extant system. Once the potential value of systems change is demonstrated, implementation research can be pursued to determine if change is actually happening, as planned, or if organizational or administrative interventions are required to improve the pace, coverage, or quality of the utilization of proven strategies, processes, or outcomes.
The principal limitation of the Schwarz et al. paper is its pursuit of secondary implementation research before essential primary impact research has been conducted. There is no evidence that deploying 20,000 volunteer CHW incrementally improves population health and well-being in the context of Ghana’s CHPS program, with its existing extensive community-based staff deployment and service capability. Nor has the deployment of CHW been shown to effectively substitute for CHPS in localities where coverage CHPS coverage has yet to be established. A pilot of CHW deployment was conducted in six districts of the Ashanti Region, but the health and survival impact of CHW deployment were untested by this investigation.35
Does the organizational design of the CHW program make sense? Key organizational and management features of CHW deployment in Ghana are unusual, and prospects for organizational challenges are likely. For example, CHW are deployed to the Ghana Health Service (GHS) system, but are not GHS employees. The program is implemented by the Ministry of Youth and Sports as a national large scale scheme for fostering employment of youth who are provided with two year contracts.5 Although CHW job descriptions are somewhat imprecise, policy documents specify clinical functions for CHW that resemble elements of the roles of CHPS nurses.5 Procedural integration of this new volunteer cadre into the national primary health care system with supervisory arrangements requires CHW to report to CHPS nurses or other primary health care paramedics. Although some documents of the 1 Million CHW Campaign suggest that CHW are health promoters rather than health providers,35 the national goal is to supplement CHPS by adding a partially compensated CHW volunteer cadre that is employed by one ministry to supplement the clinical service work of another ministry. CHW training is managed by an international non-profit organization, not the manpower development programs of the GHS. The impact of this organizational design remains unknown.
Does adding volunteer service providers to CHPS improve primary health care impact? The record of volunteer-based programs is mixed, at best, in Ghana.20 For example, in the 1980s, UNICEF promoted a volunteer deployment scheme that was termed the “Bamako Initiative.” 36,37 When the child survival impact of this approach was tested in a four celled trial in Ghana, the volunteer cell of the trial was found to have no child survival impact.38,39 Social mobilization activities of volunteers have proved to be crucial to effective family planning promotion, but their added value as independent health service providers has never been demonstrated in Ghana.40 CHW have 28 weeks of training, as noted by Schwarz et al.. CHW are allowed to provide a first dose of antibiotics for acute respiratory illness and other primary care curative modalities, but not the full regimen of treatment that global policy pronouncements recommend. Their role is therefore best described as “partial iCCM,” augmented in some localities by tele-medicine support.35 Unlike CHO, who are trained to provide a full regimen of family planning modalities, CHW are also partial family planning workers, allowed to distribute pills and condoms, but not to provide the more popular methods, injectables or subdermal methods. Partial systems of care, provided by lightly trained and poorly compensated workers, can introduce unanticipated clinical risks, particularly if substandard care diverts parental health seeking from competent sources of care.41,42
Is there a need to increase community worker manpower density? While the 1 Million CHW Campaign was implemented in response to evidence that CHPS coverage was incomplete43 subsequent actions of the Government of Ghana have rapidly increased CHPS coverage nationwide.44 This has involved a major program of expanding the numbers of trained community nurses, in response to evidence consistently showing that the community deployment of trained nurses can save lives.4 A CHPS nurse, termed “Community Health Officer (CHO), has 18 months of clinical training augmented with a six month practicum assignment in primary care delivery. However, ever since the launching of the CHPS initiative in 2000, there have been more CHOs who are available for posting than there are locations where they can reside and provide care. Shortages of equipment, supplies, and facilities were the major impediment to expanding CHPS program implementation in its first decade of operation. In 2009, a comprehensive review of the CHPS program was commissioned by the Ministry of Health that identified organizational, leadership, and resource challenges as primary constraints to implementation.45 At no point does this review recommend the addition of a new volunteer cadre. Rather, leadership lapses and resource shortages were found to be the critical barriers to expanding CHPS coverage in its first decade of operation. In response to this review, high level Government of Ghana commitment to CHPS was directed to increasing investment in the costs of CHPS geographic expansion. Ghana Health Service monitoring results suggest that geographic coverage of the CHPS program accelerated markedly since these reforms were instituted. Central to the reform agenda was expanding investment in community-based facilities where nurses could live and provide services. The volume of nurse recruitment and training was also expanded. This set of commitments appears to have worked. If rates of expansion achieved by 2012 have been sustained as planned, CHPS will reach all rural communities by 2021.46
Is a systems perspective guiding CHW deployment? If rural workers provide the internationally endorsed regimen of integrated community case management for malaria, respiratory illness, and diarrheal diseases, health impact is highly likely to follow.47,19 But potentially effective services can fail to have their intended impact if their introduction is counter-systemic. The 1 Million CHW Campaign workers are recruited and paid an honorarium of $50 per month by the Ministry of Youth and Sports. Then, after training spanning 28 weeks, CHW are deployed to their home communities with instruction to liaise with GHS units where they are to be supervised by resident CHO with the expectation that CHW will provide services that supplement care provided by their CHO supervisors.5 The Schwarz et al. analysis focuses on the intensity of nurse supervision of CHW only, and not on the question of whether CHW are needed at all.
Does the addition of CHW solve CHPS operational problems? The CHPS initiative is encountering significant implementation challenges. The quality of its services are sometimes substandard,48 management and supervisory lapses are problematic,49,50 CHPS outreach and referral activities are incomplete,51,50 links to the National Health Insurance Scheme are fragmentary, and leadership problems persist in many districts.45 Official monitoring shows that coverage of functional CHPS units is still incomplete in some districts.44 But, whether these problems are appropriately solved by adding 20,000 Ministry of Youth and Sports CHW to the overall system of care, or rather are best resolved by improving CHPS itself merits investigation. A trial of CHPS system reform has demonstrated ways to address such challenges.54,55 Other such trials are either completed or in progress54–57 some showing that CHPS can be an effective mechanism for the provision of essential primary care.8,9,47 What is needed next is a systems trial of CHPS reform that includes CHW, with a counter-factual condition that lacks CHW, followed by evidence-guided scale up of lessons learned.58
Conclusion:
We have found no evidence to support the proposition that adding CHW manpower to the existing CHPS program saves lives, improves child health, or augments CHPS effectiveness in any way. If that evidence exists, then this literature should be cited by Schwarz et al. as justification for their implementation research project. Or, if this evidence does not exist, the Campaign’s CHW deployment strategy merits the fielding of a trial with health indicators or survival endpoints. Then, based on evidence that the strategy can improve health or save lives in the context of the CHPS primary care program, there would be sound justification for pursuing implementation science that investigates the functionality of supervision in the scaled-up program. The rationale for conducting implementation science must be grounded in primary evidence that adding CHW volunteers to CHPS adds value. But, to the knowledge of the authors of this commentary, this evidence does not yet exist.
References
1. Schwarz D, Kim J-H, Ratcliffe H, et al. The status of Ghanaian community health workers’ supervision and service delivery: descriptive analyses from the 2017 Performance Monitoring and Accountability 2020 survey. Gates Open Res. 2019;3:1468. doi:10.12688/gatesopenres.12979.2
2. Singh P, Sachs JD. 1 million community health workers in sub-Saharan Africa by 2015. Lancet (London, England). 2013;382(9889):363-365. doi:10.1016/S0140-6736(12)62002-9
3. Ghana Health Service. The Community-Based Health Planning and Services (CHPS) Initiative. Accra, Ghana; 1999.
4. Ghana Health Service. Community-Based Health Planning and Services: Operational Policy. Accra, Ghana; 2015.
5. Ghana Health Service Family Health Division and the Policy Planning Monitoring and Evaluation Division. Ghana Community Health Workers Program Implementation Guidelines: Strengthening Community-Based Health Planning and Services (CHPS) For Universal Health Coverage.: A Report of the Community Health Worker Implementing Partners: The Youth Employment Agency,. Accra, Ghana; 2016.
6. Binka FN, Nazzar AK, Phillips JF, Fred N B, Adongo PB, Debpuur C. The Navrongo Community Health and Family Planning Project. Stud Fam Plann. 1995;26(3):121-139.
7. Nazzar AK, Adongo PB, Binka FN, Phillips JF, Debpuur C. Developing a culturally appropriate family planning program for the Navrongo experiment. Stud Fam Plann. 1995;26(6):307-324.
8. Awoonor-Williams JK, Feinglass ES, Tobey R, et al. Bridging the gap between evidence-based innovation and national health-sector reform in Ghana. Stud Fam Plann. 2004;35(3):161-177. doi:10.1111/j.1728-4465.2004.00020.x
9. Awoonor-Williams JK, Sory EK, Phillips JF, Nyonator FK. A case study in successful health system development in a challenging environment: Rapid progress with scale-up of community-based primary health care in an impoverished region of northern Ghana. In: Accra, Ghana; 2013:1-15.
10. Nyonator FK, Awoonor-Williams JK, Phillips JF, Jones TC, Miller RA. The Ghana Community-based Health Planning and Services Initiative for scaling up service delivery innovation. Health Policy Plan. 2005;20(1). doi:10.1093/heapol/czi003
11. Awoonor-Williams JK, Phillips JF, Bawah AA. Scaling down to scale-up: Ghana’s strategy for achieving health for all at last. J Glob Heal Sci. 2019;1(1):e9. https://e-jghs.org/DOIx.php?id=10.35500/jghs.2019.1.e9.
12. Perry HB, Zulliger R, Rogers MM. Community health workers in low-, middle-, and high-income countries: an overview of their history, recent evolution, and current effectiveness. Annu Rev Public Health. 2014;35:399-421. doi:10.1146/annurev-publhealth-032013-182354
13. Baatiema L, Sumah AM, Tang PN, Ganle JK. Community health workers in Ghana: the need for greater policy attention. BMJ Glob Heal. 2016;1(4):e000141. doi:10.1136/bmjgh-2016-000141
14. Young M, Wolfheim C, Marsh DR, Hammamy D. World Health Organization/United Nations Children’s Fund Joint Statement on Integrated Community Case Management: An Equity-Focused Strategy to Improve Access to Essential Treatment Services for Children. Am J Trop Med Hyg. 2012;87(5_Suppl):6-10. doi:10.4269/ajtmh.2012.12-0221
15. Marsh DR, Gilroy KE, Van de Weerdt R, Wansi E, Qazi S. Community case management of pneumonia: at a tipping point? Bull World Health Organ. 2008;86:381-389. doi:10.1590/S0042-96862008000500016
16. Scott K, Beckham SW, Gross M, et al. What do we know about community-based health worker programs? A systematic review of existing reviews on community health workers. Hum Resour Health. 2018;16(1):39. doi:10.1186/s12960-018-0304-x
17. Black RE, Taylor CE, Arole S, et al. Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 8. summary and recommendations of the expert panel. J Glob Health. 2017;7(1). doi:10.7189/jogh.07.010908
18. Laínez YB, Wittcoff A, Mohamud AI, Amendola P, Perry HB, D’Harcourt E. Insights from Community Case Management Data in Six Sub-Saharan African Countries. Am J Trop Med Hyg. 2012;87(5_Suppl):144-150. doi:10.4269/ajtmh.2012.12-0106
19. Prosnitz D, Herrera S, Coelho H, Moonzwe Davis L, Zalisk K, Yourkavitch J. Evidence of Impact: iCCM as a strategy to save lives of children under five. J Glob Health. 2019;9(1):010801. doi:10.7189/jogh.09.010801
20. Daniels K, Sanders D, Daviaud E, Doherty T. Valuing and sustaining (or not) the ability of volunteer community health workers to deliver integrated community case management in northern Ghana: A qualitative study. PLoS One. 2015;10(6):e0126322. doi:10.1371/journal.pone.0126322
21. World Health Organization. Universal Health Coverage Choices Facing Purchasers. Geneva, Switzerland: World Health Organization; 2016. https://www.who.int/health_financing/topics/benefit-package/UHC-choices-facing-purchasers/en/. Accessed June 16, 2019.
22. Druetz T, Siekmans K, Goossens S, Ridde V, Haddad S. The community case management of pneumonia in Africa: a review of the evidence. Health Policy Plan. 2015;30(2):253-266. doi:10.1093/heapol/czt104
23. World Health Organization and World Bank. Tracking Universal Health Coverage: First Global Monitoring Report. Geneva, Switzerland: The World Health Organization; 2015. https://books.google.com/books?hl=en&lr=&id=d140DgAAQBAJ&oi=fnd&pg=PP1&dq=Africa+contraception+OR+%22family+planning%22+OR+%22reproductive+health%22+%22universal+health+coverage%22&ots=zpJW1hP_Zx&sig=u8SI_IWY8-DCkxhQ8GRr67mEfKk#v=onepage&q=Africa contra. Accessed April 4, 2019.
24. Boone P, Elbourne D, Fazzio I, et al. Effects of community health interventions on under-5 mortality in rural Guinea-Bissau (EPICS): A cluster-randomised controlled trial. Lancet Glob Heal. 2016;4(5):e328-e335. doi:10.1016/S2214-109X(16)30048-1
25. Binka FN, Bawah AA, Phillips JF, Hodgson A, Adjuik M, MacLeod B. Rapid achievement of the child survival millennium development goal: Evidence from the Navrongo experiment in Northern Ghana. Trop Med Int Heal. 2007;12(5). doi:10.1111/j.1365-3156.2007.01826.x
26. Haines A, Sanders D, Lehmann U, et al. Achieving child survival goals: potential contribution of community health workers. Lancet. 2007;369(9579):2121–2131. doi:10.1016/S0140-6736(07)60325-0
27. McGorman L, Marsh DR, Guenther T, et al. A Health Systems Approach to Integrated Community Case Management of Childhood Illness: Methods and Tools. Am J Trop Med Hyg. 2012;87(5_Suppl):69-76. doi:10.4269/ajtmh.2012.11-0758
28. Assan A, Takian A, Aikins M, Akbarisari A. Universal health coverage necessitates a system approach: an analysis of Community-based Health Planning and Services (CHPS) initiative in Ghana. Global Health. 2018;14(Article number 107). https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-018-0426-x.
29. Scott K, Beckham SW, Gross M, et al. What do we know about community-based health worker programs? A systematic review of existing reviews on community health workers. Hum Resour Health. 2018;16(1):39. doi:10.1186/s12960-018-0304-x
30. Hawkes M, Katsuva JP, Masumbuko CK. Use and limitations of malaria rapid diagnostic testing by community health workers in war-torn Democratic Republic of Congo. Malar J. 2009;8(1):308. doi:10.1186/1475-2875-8-308
31. Kelly JM, Osamba B, Garg RM, et al. Community health worker performance in the management of multiple childhood illnesses: Siaya District, Kenya, 1997-2001. Am J Public Health. 2001;91(10):1617-1624. doi:10.2105/ajph.91.10.1617
32. Barnett C, Masset E, Dogbe T, et al. Impact Evaluation of the Savannah Accelerated Development Authority (SADA) Millennium Villages Project in Northern Ghana: Endline Summary Report. Hove, United Kingdom; 2018.
33. Remme JHF, Adam T, Becerra-Posada F, et al. Defining research to improve health systems. PLoS Med. 2010;7(11):e1001000. doi:10.1371/journal.pmed.1001000
34. Sanders D, Haines A. Implementation Research Is Needed to Achieve International Health Goals. PLoS Med. 2006;3(6):e186. doi:10.1371/journal.pmed.0030186
35. Nsarko NE, Baah JS, Akosah E, Mahama JE, Azasi E. Reaching the Rural Poor through E-Health Enhanced Community Health Workers (CHWS). Accra, Ghana; 2017. http://ic-sd.org/wp-content/uploads/sites/4/2018/02/Chief-Nathaniel-Ebo-Nsarko.pdf.
36. Chabot J. The Bamako initiative. Lancet. 1988;332(8624):1366-1367.
37. Knippenberg R, Levy-Bruhl D, Osseni R, Drame K, Soucat A, Debeugny C. The Bamako initiative: Primary health care experience. Child Trop. 1990;184/185:94.
38. Binka FN, Bawah AA, Phillips JF, Hodgson A, Adjuik M, Macleod BB. Rapid achievement of the child survival millennium development goal: evidence from the Navrongo experiment in Northern Ghana. Trop Med Int Health. 2007;12(5):578-583. doi:10.1111/j.1365-3156.2007.01826.x
39. Wells Pence B, Nyarko P, Phillips JF, Debpuur C. The effect of community nurses and health volunteers on child mortality: The Navrongo Community Health and Family Planning Project. Scand J Public Health. 2007;35(6). doi:10.1080/14034940701349225
40. Phillips JF, Bawah AA, Binka FN. Accelerating reproductive and child health programme impact with community-based services: the Navrongo experiment in Ghana. Bull World Health Organ. 2006;84(12):949-955. doi:S0042-96862006001200010 [pii]
41. Pence BW, Nyarko P, Phillips JF, Debpuur C. The effect of community nurses and health volunteers on child mortality: the Navrongo Community Health and Family Planning Project. Scand J Public Health. 2007;35(6):599-608. doi:10.1080/14034940701349225
42. Nyarko P, Pence B, Adongo P. Child morbidity and health-seeking behaviour of primary caretakers in the Kassena-Nankana District of northern Ghana. 2004.
43. Government of Ghana. National Community Health Worker Program. Ghana Roadmap: One Million Community Health Workers Campaign. Accra, Ghana; 2014.
44. Ghana Health Service. Annual Report 2016. Accra, Ghana; 2017. http://www.ghanahealthservice.org/ghs-item-details.php?cid=5&scid=52&iid=127.
45. Binka FN, Aikins M, Sackey SO, et al. In-Depth Review of the Community-Based Health Planning Services (CHPS) Programme A Report of the Annual Health Sector Review, 2009. Accra, Ghana; 2009.
46. Ghana Health Service. Community-Based Health Planning and Services, Annual Report 2016. Accra, Ghana; 2017.
47. Ferrer BE, Webster J, Bruce J, et al. Integrated community case management and community-based health planning and services: a cross sectional study onthe effectiveness of the national implementation for the treatment of malaria, diarrhoea and pneumonia. Malar J. 2016;15:340. doi:10.1186/s12936-016-1380-9
48. Atinga RA, Agyepong IA, Esena RK. Ghana’s community-based primary health care: Why women and children are ‘disadvantaged’ by its implementation. Soc Sci Med. 2018;201:27-34. doi:10.1016/J.SOCSCIMED.2018.02.001
49. Frimpong JA, Helleringer S, Awoonor-Williams JK, Yeji F, Phillips JF. Does supervision improve health worker productivity? Evidence from the Upper East Region of Ghana. Trop Med Int Heal. 2011;16(10). doi:10.1111/j.1365-3156.2011.02824.x
50. Bonenberger M, Aikins M, Akweongo P, Bosch-Capblanch X, Wyss K. What Do District Health Managers in Ghana Use Their Working Time for? A Case Study of Three Districts. Molyneux S, ed. PLoS One. 2015;10(6):e0130633. doi:10.1371/journal.pone.0130633
51. Assan A, Takian A, Aikins M, Akbarisari A. Challenges to achieving universal health coverage through community-based health planning and services delivery approach: a qualitative study in Ghana. BMJ Open. 2019;9(2):e024845. doi:10.1136/bmjopen-2018-024845
52. Patel SN, Awoonor-Williams JK, Asuru R, et al. Lessons Learned from a Community-Engaged Emergency Referral Systems-Strengthening Initiative in a Remote, Impoverished Setting of Northern Ghana. New York, New York; 2015.
53. Patel S, Awoonor-Williams JK, Asuru R, et al. Benefits and limitations of a community-engaged emergency referral system in a remote, impoverished setting of Northern Ghana. Glob Heal Sci Pract. 2016;4(4). doi:10.9745/GHSP-D-16-00253
54. Bawah AA, Awoonor-Williams JK, Asuming PO, et al. The child survival impact of the Ghana Essential Health Interventions Program: A health systems strengthening plausibility trial in Northern Ghana. Kamath-Rayne B, ed. PLoS One. 2019;14(6):e0218025. doi:10.1371/journal.pone.0218025
55. Awoonor-Williams JK, Bawah AA, Nyonator FK, et al. The Ghana essential health interventions program: a plausibility trial of the impact of health systems strengthening on maternal & child survival. BMC Health Serv Res. 2013;13(Suppl 2):S3. doi:10.1186/1472-6963-13-S2-S3
56. Stanton CK, Newton S, Mullany LC, et al. Effect on Postpartum Hemorrhage of Prophylactic Oxytocin (10 IU) by Injection by Community Health Officers in Ghana: A Community-Based, Cluster-Randomized Trial. Middleton P, ed. PLoS Med. 2013;10(10):e1001524. doi:10.1371/journal.pmed.1001524
57. Chinbuah MA, Kager PA, Abbey M, et al. Impact of Community Management of Fever (Using Antimalarials With or Without Antibiotics) on Childhood Mortality: A Cluster-Randomized Controlled Trial in Ghana. Am J Trop Med Hyg. 2012;87(5_Suppl):11-20. doi:10.4269/ajtmh.2012.12-0078
58. Phillips JF, Awoonor-Williams JK, Bawah AA, et al. What do you do with success? the science of scaling up a health systems strengthening intervention in Ghana. BMC Health Serv Res. 2018;18(1). doi:10.1186/s12913-018-3250-3
[1] Professor Emeritus, Mailman School of Public Health, Columbia University, New York, USA.
[2] Founding Vice Chancellor, University of Health and Allied Sciences, Ho, Volta Region, Ghana.
James F. Phillips, MS, PhD[1]
Fred N. Binka, MD, MPH, PhD[2]
Commentary on:
The status of Ghanaian community health workers’ supervision and service delivery: descriptive analyses from the 2017 Performance Monitoring and Accountability 2020 survey
by
Dan Schwarz, June-Ho Kim, Hannah Ratcliffe, Griffith Bell, John Koku Awoonor-Williams,
Belinda Nimako, Easmon Otupiri, Stuart Lipsitz, Lisa Hirschhorn, and Asaf Bitton
Gates Open Research. 2019;3:1468. doi:10.12688/gatesopenres.12979.2
Background:
In May, 2019, Gates Open Research published an implementation scientific investigation of a program in Ghana that has assigned a new cadre of volunteer community health workers to an existing program of community-based nursing services.1 Entitled “The status of Ghanaian community health workers’ supervision and service delivery: descriptive analyses from the 2017 Performance Monitoring and Accountability 2020 survey,” the paper was a carefully prepared appraisal of the question: Is supervision associated with a new program for assigning Community Health Workers (CHW) being effectively implemented? The program in focus represents Ghana’s response to an international initiative known as the One Million Community Health Worker Campaign which aims to expand community-based primary health care coverage throughout Africa.2 Launched in 2014 in Ghana, the Campaign was intended to augment an existing program, known by the acronym, “CHPS,” for Community-based Health Planning and Services. 3–5 The CHPS program was researched in the 1990s,6–8 adopted as national policy in 1999, and launched as a national scaling-up program in 2000.9,10 When monitoring during its first decade of operation showed that CHPS was not achieving its planned expansion goals, reforms were instituted that have accelerated CHPS coverage in the second decade of CHPS operation.11 In this context of reform and action, the “One Million CHW Campaign” was also launched in 2014, with the goal of adding a cadre of semi-volunteer personnel, community services, and care to the existing CHPS agenda.2,5
The CHPS program and the CHW initiative are being undertaken in conjunction with CHW deployment policy proliferation throughout sub-Saharan Africa. 12,13 Evidence from cross-national literature reviews showing that deployment in rural settings of South Asia and sub-Saharan Africa can save lives14–18 has fostered international endorsement of the regimen of care that is known as “Integrated Management of Childhood Illness (iCCM),19,20 a core strategy for achieving universal health coverage (UHC) in resource deprived settings.21 Although the need to launch iCCM in Ghana is without question, research also attests to the need for careful primary impact appraisals wherever manpower for addressing this goal is added to an existing system of community based primary health care.22 Home visitation by CHW has been shown to have potential for mortality reducing impact among neonates,23 and iCCM, if appropriately delivered, can accelerate reductions in childhood mortality.14,15,24–26 But, evidence also shows that systems thinking is critical to CHW success,27,28 and context specific evaluation is important since integration of CHW into the broader health system is critically important,29 since systems differ markedly by country, and failure to integrate CHW into systems of work, supervision, leadership, and logistics can lead to interlocking problems and unanticipated adverse outcomes.30,31
Comments on the Schwarz et al. publication:
It is against this contextual backdrop that we direct this commentary. The Schwarz et al. paper was a carefully conducted implementation study that is nonetheless pointless. If primary research had been conducted showing that CHW deployment program saves lives or improves health when it is functioning, then the quality or intensity of supervision of its large scale operation would be of paramount importance. But, in the absence of this primary evidence, implementation research does not matter. It is possible that the package of services that CHW are deployed to provide could save lives, if the services cited by Schwarz et al. are actually provided and if these workers do so in isolation of population exposure to other components of Ghana’s primary health care system. But, there is ample reason to question whether the addition of a cadre to CHPS, as envisioned by the 1 Million CHW campaign, is sound:
Has primary research demonstrated that supplementing CHPS with CHW adds value? The CHW program was piloted as an add-on to the Millennium Village Project (MVP) in six districts of the Ashanti Region. When the MVP was replicated in study districts in the Northern and Upper East Regions, the project had only marginal effects on some health indicators, and no discernible survival impact.32 Primary impact research on CHW deployment is needed: Adding CHW to a failed MVP strategy may or may not add value to services already provided by CHPS. The survival effects of adding CHW to Ghana’s system of primary health care remains unknown.
The concept of phasing research methodologies is important in this instance. The Schwarz et al. article is an application of implementation science, a type of health systems investigation that assesses the causes, consequences and challenges associated with bringing to scale proven improvements in health technology, service quality, or changes in systems of care.33,34 Investigating the gap between innovation potential and actual system functioning can be the subject of a wide variety of types of investigations involving experiments, qualitative diagnostic research, or quantitative appraisals of system functioning. However, Holl such work is predicated on the prospect that the concept in question is, in fact, proven to have potential benefits. This requires prior completion of primary research establishing the fundamental value of changing operations according to a proven alternative to the extant system. Once the potential value of systems change is demonstrated, implementation research can be pursued to determine if change is actually happening, as planned, or if organizational or administrative interventions are required to improve the pace, coverage, or quality of the utilization of proven strategies, processes, or outcomes.
The principal limitation of the Schwarz et al. paper is its pursuit of secondary implementation research before essential primary impact research has been conducted. There is no evidence that deploying 20,000 volunteer CHW incrementally improves population health and well-being in the context of Ghana’s CHPS program, with its existing extensive community-based staff deployment and service capability. Nor has the deployment of CHW been shown to effectively substitute for CHPS in localities where coverage CHPS coverage has yet to be established. A pilot of CHW deployment was conducted in six districts of the Ashanti Region, but the health and survival impact of CHW deployment were untested by this investigation.35
Does the organizational design of the CHW program make sense? Key organizational and management features of CHW deployment in Ghana are unusual, and prospects for organizational challenges are likely. For example, CHW are deployed to the Ghana Health Service (GHS) system, but are not GHS employees. The program is implemented by the Ministry of Youth and Sports as a national large scale scheme for fostering employment of youth who are provided with two year contracts.5 Although CHW job descriptions are somewhat imprecise, policy documents specify clinical functions for CHW that resemble elements of the roles of CHPS nurses.5 Procedural integration of this new volunteer cadre into the national primary health care system with supervisory arrangements requires CHW to report to CHPS nurses or other primary health care paramedics. Although some documents of the 1 Million CHW Campaign suggest that CHW are health promoters rather than health providers,35 the national goal is to supplement CHPS by adding a partially compensated CHW volunteer cadre that is employed by one ministry to supplement the clinical service work of another ministry. CHW training is managed by an international non-profit organization, not the manpower development programs of the GHS. The impact of this organizational design remains unknown.
Does adding volunteer service providers to CHPS improve primary health care impact? The record of volunteer-based programs is mixed, at best, in Ghana.20 For example, in the 1980s, UNICEF promoted a volunteer deployment scheme that was termed the “Bamako Initiative.” 36,37 When the child survival impact of this approach was tested in a four celled trial in Ghana, the volunteer cell of the trial was found to have no child survival impact.38,39 Social mobilization activities of volunteers have proved to be crucial to effective family planning promotion, but their added value as independent health service providers has never been demonstrated in Ghana.40 CHW have 28 weeks of training, as noted by Schwarz et al.. CHW are allowed to provide a first dose of antibiotics for acute respiratory illness and other primary care curative modalities, but not the full regimen of treatment that global policy pronouncements recommend. Their role is therefore best described as “partial iCCM,” augmented in some localities by tele-medicine support.35 Unlike CHO, who are trained to provide a full regimen of family planning modalities, CHW are also partial family planning workers, allowed to distribute pills and condoms, but not to provide the more popular methods, injectables or subdermal methods. Partial systems of care, provided by lightly trained and poorly compensated workers, can introduce unanticipated clinical risks, particularly if substandard care diverts parental health seeking from competent sources of care.41,42
Is there a need to increase community worker manpower density? While the 1 Million CHW Campaign was implemented in response to evidence that CHPS coverage was incomplete43 subsequent actions of the Government of Ghana have rapidly increased CHPS coverage nationwide.44 This has involved a major program of expanding the numbers of trained community nurses, in response to evidence consistently showing that the community deployment of trained nurses can save lives.4 A CHPS nurse, termed “Community Health Officer (CHO), has 18 months of clinical training augmented with a six month practicum assignment in primary care delivery. However, ever since the launching of the CHPS initiative in 2000, there have been more CHOs who are available for posting than there are locations where they can reside and provide care. Shortages of equipment, supplies, and facilities were the major impediment to expanding CHPS program implementation in its first decade of operation. In 2009, a comprehensive review of the CHPS program was commissioned by the Ministry of Health that identified organizational, leadership, and resource challenges as primary constraints to implementation.45 At no point does this review recommend the addition of a new volunteer cadre. Rather, leadership lapses and resource shortages were found to be the critical barriers to expanding CHPS coverage in its first decade of operation. In response to this review, high level Government of Ghana commitment to CHPS was directed to increasing investment in the costs of CHPS geographic expansion. Ghana Health Service monitoring results suggest that geographic coverage of the CHPS program accelerated markedly since these reforms were instituted. Central to the reform agenda was expanding investment in community-based facilities where nurses could live and provide services. The volume of nurse recruitment and training was also expanded. This set of commitments appears to have worked. If rates of expansion achieved by 2012 have been sustained as planned, CHPS will reach all rural communities by 2021.46
Is a systems perspective guiding CHW deployment? If rural workers provide the internationally endorsed regimen of integrated community case management for malaria, respiratory illness, and diarrheal diseases, health impact is highly likely to follow.47,19 But potentially effective services can fail to have their intended impact if their introduction is counter-systemic. The 1 Million CHW Campaign workers are recruited and paid an honorarium of $50 per month by the Ministry of Youth and Sports. Then, after training spanning 28 weeks, CHW are deployed to their home communities with instruction to liaise with GHS units where they are to be supervised by resident CHO with the expectation that CHW will provide services that supplement care provided by their CHO supervisors.5 The Schwarz et al. analysis focuses on the intensity of nurse supervision of CHW only, and not on the question of whether CHW are needed at all.
Does the addition of CHW solve CHPS operational problems? The CHPS initiative is encountering significant implementation challenges. The quality of its services are sometimes substandard,48 management and supervisory lapses are problematic,49,50 CHPS outreach and referral activities are incomplete,51,50 links to the National Health Insurance Scheme are fragmentary, and leadership problems persist in many districts.45 Official monitoring shows that coverage of functional CHPS units is still incomplete in some districts.44 But, whether these problems are appropriately solved by adding 20,000 Ministry of Youth and Sports CHW to the overall system of care, or rather are best resolved by improving CHPS itself merits investigation. A trial of CHPS system reform has demonstrated ways to address such challenges.54,55 Other such trials are either completed or in progress54–57 some showing that CHPS can be an effective mechanism for the provision of essential primary care.8,9,47 What is needed next is a systems trial of CHPS reform that includes CHW, with a counter-factual condition that lacks CHW, followed by evidence-guided scale up of lessons learned.58
Conclusion:
We have found no evidence to support the proposition that adding CHW manpower to the existing CHPS program saves lives, improves child health, or augments CHPS effectiveness in any way. If that evidence exists, then this literature should be cited by Schwarz et al. as justification for their implementation research project. Or, if this evidence does not exist, the Campaign’s CHW deployment strategy merits the fielding of a trial with health indicators or survival endpoints. Then, based on evidence that the strategy can improve health or save lives in the context of the CHPS primary care program, there would be sound justification for pursuing implementation science that investigates the functionality of supervision in the scaled-up program. The rationale for conducting implementation science must be grounded in primary evidence that adding CHW volunteers to CHPS adds value. But, to the knowledge of the authors of this commentary, this evidence does not yet exist.
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[1] Professor Emeritus, Mailman School of Public Health, Columbia University, New York, USA.
[2] Founding Vice Chancellor, University of Health and Allied Sciences, Ho, Volta Region, Ghana.