There has been considerable improvement in the health status of Ghanaians since independence. However, the rate of change has been slow and current health indicators are still far from acceptable. Maternal mortality rates, child mortality and morbidity rates still remain high; Malaria and other communicable diseases including HIV/AIDS are persistent.
According to the 2007 Ghana Human Development Report, current indicators prove that maternal mortality rates have not improved significantly in the past five years, ranging between 204/100,000 in 2002 to 187/100,000 life births in 2006. In the same regard, infant mortality rates have equally remained high with very little improvement; as far back as 1999 infant mortality has increased to 71 deaths per 1000 live births while under-five mortality increased to 111 in 2003 and has remained the same in 2006.
Improving upon health service delivery and making basic and primary health care accessible to all Ghanaians has been a priority issue for government, it is in this regard that the government of Ghana has adopted the Millennium Development Goal (MDG) target with the aim of reducing maternal mortality, as a result in developing health policies the government is guided by three essential goals in health service delivery. This is to ensure that all individuals irrespective of ones geographical location enjoys a good and healthy life, below are the goals;
" to maximize the total number of healthy lives of Ghanaians and all persons resident in Ghana regardless of age, sex, origins, ethnic group, religion, political beliefs or socio-economic standing ( to increase the span of healthy life for Ghanaians and persons resident in Ghana.
To achieve universal access to promotive and preventive services and emergency curative services to all Ghanaians resident in Ghana.
To reduce the disparities in health status among rural, periurban and urban communities. Special attention is needed to close the gap between rural and urban dwellers; between the well-off and people with low income, between children and adults" (Kunfaa : 1996)
Various interventions have been put in place to make health service accessible to all, however using evidence of success from other research projects such as the Danfa Comprehensive Rural Health and Family planning project and the WHO-sponsored Brong Ahafo Regional Development project, the MoH initiated the Village Health Workers (VHW) system, unfortunately during the scaling up of the system it encountered organizational, training, resource and supervision setbacks. However in 1980, the system was abandoned (Cole-King et.al 1976 as cited by Frank Nyonator et.al 2001).
"in response to criticisms of the volunteer approach, a new type of paid worker was created was in the 1980s, termed Community Health Nurses, to provide more professional, and potentially more acceptable and effective, services than village health workers" (NHRC: 1999).
Instead of placing community health workers in communities, they worked from the sub-district health centers. Despite the fact that outreach clinics formed part of the community health nurse's duties, community outreach remained static, however timing of outreach was not stable as a result of logistics constrains ( Frank Nyonator et.al 2001).
It is against this backdrop that the Ministry of Health (MoH) in 1997 launched a Health Sector Reform (HSR) process basically aimed at improving both geographical and financial access to basic and quality health care as well as ensuring efficiency in the services provided. In 1998, the Community based Health Planning and Services (CHPS) initiative was developed by the MoH purposely to improve geographical access, equity, quality and efficiency of basic and primary health care (Frank Nyonator et.al 2001).
"The Community-based Planning and Services (CHPS) initiative is a programme designed to translate innovations from an experimental study of the Navrongo Health Research Center (NHRC) into a national programme for improving accessibility, efficiency and quality of health and family planning services". (Binka et al.1995; Pence et al. 2001; Debpuur et al .2002).
The CHPS initiative has become a national health strategy initiated to provide community-based health service and to deal with the issue of inequality in access to primary health care and thereby reducing health inequalities and promote equity of health outcomes.
The question however which needs in depth studies is whether the CHPS initiative has succeeded in improving access to quality health care in the Lawra District? If not, then what are the challenges that confronts the initiative as well as the opportunities available that can be exploited to make health care more accessible in the Lawra District?.
The initiative is expected to have a three tier level system of service provision within a district, the District (Hospital) level, the Sub-District (Health Centre) level and community-based. As captured above, geographical access is a major barrier to health care and as such, the initiative is set out to improve geographic access to services. In line with this health service delivery strategy, the number of health facilities doubled over the first and second five-year programme of work at the Sub-district and the District levels, but exacerbated by the 'brain drain', the investment in the Sub-district did not remove the barriers to health care (CHPS Operational Policy Document May 2005).
As part of governments efforts towards enhancing development, particularly in rural Ghana in areas of poverty reduction, human resource development, illiteracy, unemployment, reduction in maternal and child mortality rates, inequality in access to social and economic infrastructure, the government of Ghana launched the Ghana-Vision 2020, Ghana Poverty Reduction Strategy (GPRS I) and the Growth and Poverty Reduction Strategy (GPRS II), with the aim of reducing poverty and improving the economy.
The National Health Care system primarily aims at improving equity and access to primary health care and also ensuring that the health sector plays an essential role in the national poverty reduction. The objectives of the health care system are built around improving geographic, financial and socio-cultural access to quality health care (Adapted from GHDR: 2007).
1.2 Problem Statement
Generally the health status of Ghanaians has improved over the years; however considerable differences in some health indicators among different geographical regions and socio-economic groupings are evident. These variations are partly due to differential access to quality health care. In spite of the considerable investment in the provision of health care facilities, a great proportion of the people lack access to quality health services (GPRS II: 2006-2009).
"57.7% of Ghanaians have access to a health facility within 30 minutes of their places of residence. Urban localities generally enjoy good access to health compared to rural areas as urban areas tend to have a relatively better concentration of health facilities and better road network as well as other factors that enhance access. Access to health facilities in the rural areas, therefore becomes a challenge for rural inhabitants as they have to travel for considerable distances for health care, in Upper West 30.4% of the total households in the region has a health facility within 30 minutes of reach" [Core Welfare Indicator Questionnaire II (CWIQ) (Ghana Statistical Service 2003)].
In Ghana, geographic access is a major barrier to health care and strongly tied to this is an excess of childhood mortality, due to service inaccessibility. It is further stated that about 70 per cent of the Ghanaian population resides in communities that are over 5 kilometers from the nearest health facility. Childhood mortality in such communities is 40 per cent higher than in communities located within 5 kilometers of health facilities. Also, there is a great disparity in health status between urban and rural areas (GHS; 2002).
The health situation in Lawra is not different, as at 2009 infant mortality in Lawra stood at 120/1000 live births which is very high compared to the national and regional figures which are 71/1000 live births and /1000 births respectively. Again the district also recorded a high rate of babies delivered with low body weight from 73 in 2007 to 193 in 2008; this was largely due to low maternal nutrition and ill health (DMTDP 2006-2009)
According to the 2003 Ghana Demographic and Health Survey (GDHS) major health indicators such as Maternal Mortality, Infant Mortality and under-five Mortality are still unacceptably high. These stand at 214 deaths per 100 000 live births, 64 deaths per 1000 live births and 111 deaths per 1000 births respectively. It is also estimated that 'less than three fifths of the population have access to some form of modern health services'
The mal-distribution and the problems associated with geographical and financial access coupled with the attrition of highly qualified staff mean that new ways of working are required to deal with the basic elements of the poor. The CHPS strategic response takes into consideration that working with households and communities to ensure the availability of appropriate community-based services, and addressing all barriers to access at the local level are some of the most important areas that require new and innovative approaches. If this can be achieved, then key barriers would be removed (CHPS Operational Policy Document May 2005).
The study seeks to identify the contribution CHPS has made in improving access to health service delivery in the Lawra District, the challenges that face the initiative as well as the opportunities that exist for the initiative to succeed.
1.3 Research Questions
1.3.1 Main Research Question
Has the CHPS initiative improved access to health services delivery, health status and health seeking behaviour in the Lawra District?
1.3.2 Sub Research Questions
Has the CHPS initiative bridged the gap in access to basic health care in the Lawra District?
Has the CHPS initiative achieved improved efficiency and responsiveness to clients needs?
How can the development of inter-sectoral collaborations enhance the CHPS initiative?
What are the challenges and the prospects of CHPS?
What can be done to overcome the challenges?
1.4 Research Objectives
1.4.1 Main Research Objective
To assess the CHPS Initiative and its effect on improving access to health care, the health status and health seeking behaviour of people in the Lawra District.
1.4.2 Sub Research Objectives
To assess the accessibility to basic health care in rural communities in the Lawra District?
To determine the efficiency and responsiveness of the CHPS initiative to clients needs.
To identify the challenges and opportunities of the CHPS initiative in the Lawra District.
To make recommendations that would improve access and enhance health service delivery in the Lawra District.
1.5 Significance of the Study
There is a growing awareness on the need to increase access to quality health care irrespective of one's geographical location; it has therefore become imperative to encourage house hold and community involvement in health service delivery. The CHPS initiative is a national strategy developed to help bridge the gap in access to health care, this strategy seeks to help reduce health inequalities and promote equity of health outcomes by removing the geographic barriers to health care. The CHPS initiative has been perceived as an appropriate way to deliver health care to communities in deprived and distant areas (usually rural areas) from health facilities and relocating primary health care from sub-District health centres to convenient community locations. "With about 70% of the Ghanaian population living in rural areas with very little access to quality health care" (GPRS II 2006-2009), the introduction of CHPS initiative is not only timely but very appropriate.
As an initiative that has still not gained firm grounds in the Region it is however likely to be faced with a myriad of challenges which could cripple its efforts at making health service accessible to all as well as some opportunities if exploited can help strengthen the initiative, thereby making health more accessible to all. This therefore forms the basis of this study to identify the challenges and opportunities of the CHPS initiative.
1.6 Scope of the Study
The focus of this study is on rural access to Health Service delivery in CHPS zones in the Lawra District from the perspectives of the Sub-District Health Team (SDHT), Community Health Officer (CHO) and community members who are key pillars in the implementation of the CHPS initiative.
1.7 Choice of Study Area
The choice of Lawra district is because it is an area where language is not a barrier; i am familiar with the area. It is a District where the population is predominantly rural (that is settlement with a population less than 5000). Lawra District has 95% of the inhabitants in the rural area, (DHA: 2008), it is an area where the CHPS initiative has been in existence for close to ten (10) years. Though there has been some improvement in the health indicators of the district, it is far from desirable implying that maternal and infant mortality rates as well as other communicable diseases such as HIV/Aids, diarrhea, cholera are still high.
1.8 Limitations
In terms of scope the study looks at rural access to Health Service Delivery from the view point of the Sub-District Health Team (SDHT), Community Health Officer (CHO) and community members without taking in to consideration the opinions of the Regional Health Management Team (RHMT), District Health Management Team (DHMT).
In addition to the above, the study is limited in terms of coverage, this is because the study is concentrated on Lawra District as such findings of the study might not be applicable to other districts.
1.9 Organization of Report
The report will be presented in six main chapters.
Chapter one would form the introductory aspects of the report and will comprise: background/introduction to the study, problem statement, research questions and objectives, as well as the significance of the study, choice of study area, limitations and organization of report
Chapter Two will focus on review of relevant related literature and also look at the historical and conceptual frameworks of the study. Chapter Three will address methodological and analytical frameworks of the study. Emphasis shall be on sampling techniques, data collection and analytical methods. Chapter four will be centered on presentation of case descriptions from the study CHPS whilst Chapter Five will entail discussions on the major findings of the study.
Chapter Six shall comprise Summary, Conclusions and Recommendations from the study.
CHAPTER TWO
LITERATURE REVIEW
2.0 Introduction
Literature would be reviewed on past and present documentation on health care particularly primary health care, participation and the CHPS initiative, both published and unpublished literature would be reviewed as well as official reports.
Literature would be reviewed under the following themes;
Background of CHPS
CHPS policy
Vision, Goal, Objective of CHPS
Components of CHPS
Organization of community-based services
Basic package of interventions for CHPS
Health inequalities and inequities
The concept of Primary Health Care
Elements and principles of primary health care
Organization of the health system under primary health care
Philosophy and strategy of Primary Health Care
Participation
Community participation.
Community participation in health service delivery.
Factors promoting participation in health service delivery
Factors that hinder participation in health service delivery.
2.1 SUMMARY OF REVIEW
2.1.1 Community-based Health Planning and Services (CHPS).
In an effort to provide the Community-based level or 'close-to-client' doorstep health delivery with household and community involvement, the Ministry of Health through the Ghana Health Service pioneered the implementation of a national programme to replicate the results of Navrongo Community Health and Family Planning Project (CHFP) known as the Community-based Health Planning and Services (CHPS) initiative in key pilot Districts of Nkwanta, Birim North and Asebu-Abura-Kwamankese. The CHPS Initiative is therefore the national strategy for implementing the community based service delivery by reorienting and relocating primary health care from sub-District health centres to convenient community locations (GHS, 2005).
"Studies of the diffusion of organizational change have demonstrated that changes perceived as being brought from outside are more difficult to introduce than are changes perceived to be owned by host institution" (Melgaard et al. 1998; Simmons et al. 2002).
It must therefore be emphasised that the key component of the CHPS initiative is community-based service delivery point that focuses on improved partnership with households and community leaders and social groups, addressing the demand side of service provision and recognising the fact that households are the primary producers of health (GHS, 2005).
The strategic policy of the Ghana Health Service is intended to have a three tier level of service within a District. These will be the District (Hospital) level, the Sub-District (Health Centre) level and Community-based level. All sub-Districts are to be divided into zones with a catchment population of 3000 to 4500 covering up to three unit committees, where primary health care services will be provided to the population by a resident Community Health Officer, assisted by the community structures and volunteer systems. The deployment of all elements necessary such as motor bikes, bicycles for the Community Health Officer to provide house-to-house services shall make a zone a fully functional CHPS zone within a sub-District.
The Vision of the Ghana Health Service is to have all Ghanaians covered by community based service delivery using CHPS Initiative by 2015. By implementing CHPS therefore, the health sector fulfils its health system reform process of establishing a whole 'District Health System' comprising the three service delivery levels namely the Community level, Sub-District (Health Centre) Level and District (Hospital) level with strong referral components between levels. The overall goal of CHPS is to improve the health status of people living in Ghana, by facilitating actions and empowerment at household and community levels (GHS, 2005).
"Within the context of the Ghana Poverty Reduction Strategy (GPRS II), community-based health service delivery using the CHPS approach, provides a unique opportunity for achieving critical intermediate performance measures of the health sector. Also, to be able to achieve the goal and reach the vision for 2015, the objectives of the CHPS initiative must be met. There are three important objectives and these are:
Improve access to services;
Improve efficiency and responsiveness to client needs; and
Develop effective inter-sectoral collaboration" (GHS, 2005).
2.1.2 Health Inequalities and Inequities
"Inequalities and inequities in health have long been central to the concerns of public health. Governments in several countries have recently shown renewed interest in tackling these issues" (Acheson, 1998).
Health inequalities and inequities within countries are understood differently throughout the world. In countries like the United Kingdom, Sweden, and the Netherlands, much of the research on inequalities in health has been focused on the mechanisms that generate socio-economic gradients in ill health and mortality. From this perspective, the policy solutions that arise are around primary prevention. On the other hand in low and middle income countries, people working on inequalities in health tend to see the problem as one of devising policies to ensure more equitable provision of health care
There are some exceptions to this. For example, in the United States, concern about equity of access to adequate health care runs alongside an active research base on the determinants of inequalities in incidence of disease. Nevertheless, in many high income countries, as in Western Europe, access to health services is relatively universal and not strongly dependent on socioeconomic circumstances or geography. In developing countries, however, the issue of organising and funding the health sector has been more central to inequalities in health (Scott, 1999).
Gakidou et al (2000) advocate that, rather than looking at the way in which health or disease rates vary between socioeconomic groups, we should measure the distribution of health across all individuals in a population. This approach is analogous to measuring inequality in income and would estimate the spread of health (at an individual or household level) across the population.
2.1.3 Primary Health Care (PHC)
In its original definition of PHC is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community can afford to maintain at every stage of their development in the spirit of self reliance and self determination. It forms an integral part of both the country's health system of which it is a central and main focus, and of the overall social and economic development of the community (Alma Ata Conference, 1978).
Kunfaa (1996) defines Primary Health Care as a common sense, practical approach to the improvement of human health, emphasising the importance of nutrition, water and sanitation, health education, and the efficient and equitable allocation of health resources.
"Generally, the term Primary Health Care has been used to refer to the most peripheral level of health system-the first to be contacted by the public when seeking treatment. This includes such institutions as health (sub) centres, clinics, general practitioner's offices, polyclinics, etc. the PHC approach, however, stresses that the first level of care not only goes beyond the conventional system described above, but actually begins with community activities. These may include activities by the community as a whole, by families for their own benefit and by individuals through health care" (Kunfaa: 1996).
UNICEF, 1990, suggests that the first line of defence of health is the individual, the family and the community. People well armed with knowledge, and a community which is organized to press for and participate in the services it needs, are the principal agents of better health.
The PHC values to achieve health for all require health systems that "Put people at the centre of health care". What people consider desirable ways of living as individuals and what they expect for their societies, what people value constitute important parameters for governing the health sector (WHO:2008).
As far back as 1978, Ghana became a signatory to the 1978 Alma Ata Declaration and therefore adopted the Primary Health Care concept as a health strategy. However irrespective of the efforts put in place by government by way of policies, infrastructure among others very little success has been achieved. Even though some progress has been made in the area of preventable childhood disease such as polio, meseals etc. three decades down the line, the country is still confronted with high maternal mortality, infant mortality and under- five mortality.
2.1.4 Participation
The term participation has been defined differently by various scholars and intellectuals, "participation is a process of action by local people to reflect their own interests or to contribute their energies and resources to the systems which govern their lives. Participation is the process through which stakeholders' influence and share control over priority setting, policy-making, resource allocations and access to public goods and services. Stakeholder participation in projects and programmes can be a key for ensuring their long-term sustainability. Promoting participation helps build ownership and enhances transparency and accountability, and in doing so enhances effectiveness of development projects and policies" [Arnstein in Aryeetey (1992)].
Ghai (1988) perceives community participation as decentralizing central government machinery to the local level. In this approach decision-making power and resources are transferred to local officials and elected bodies in villages, communities and districts.
The health sector appears to be one area in which active involvement of rural communities seems to have achieved much result (Kunfaa: 1996). This is manifested in various illustrative statements by World Health Organization;
"community participation has been described as a process by which individuals, families or communities assume responsibility for their own health and welfare and develop the capacity to contribute their own and the community's development" (WHO,1987).
This form of participation is vigorously promoted and includes delegating responsibility to communities and creating local institutions as vehicles of participation (ibid, 1987:6).
"However the diverse nature of participation has been well articulated by Oakley and Marsden (1990) and Oakley et.al (1991). Several obstacles to participation were identified and elucidated by these writers. This notwithstanding, they assert that increased community participation would enhance project efficiency, effectiveness, self-reliance, coverage and sustainability" (Kunfaa, 1996)
CHAPTER THREE
METHODOLOGY
3.1 Introduction
This chapter entails the research methods and tools that will be used to gather data as well as the analytical tools.
3.2 Research Design
The choice of a research design depends on the control the researcher has on the phenomenon being studied, the focus of the study (whether contemporary, historical etc.), the purpose of the study, the time available for the study and the type of data involved. In the light of the above, the case study approach would be employed.
The choice of the case study approach is as a result of the fact that it is best used in the study of contemporary issues and the issue being investigated, is a contemporary phenomenon which is ongoing; this approach is mostly used for an intensive study of an individual unit, stressing factors in relation to the unit's own environment.
The case study method involves procedures and techniques of investigation, usually, but not exclusively or always based on intensive interviewing. This is aimed at enabling the investigator to grasp and understand an individual, a group, a community, a social situation or an issue in order to take decisions that take into consideration the special and peculiar circumstances surrounding the case investigated, or practical solutions relating to the case in question. The approach is also one of careful and critical inquiry or investigation and examination, seeking to analyse the factors involved in a given case, problem, community and issue, among other things, before making any suggestions or recommendations (Kumekpor: 2002).
3.3 Sampling Technique
A combination of probability and non-probability sampling methods would be employed to make the research scientific and reliable. The probability sampling technique that would be used is the simple random technique while the purposive sampling technique would be the non-probability technique.
For the study, the focus will be on rural areas within the Lawra District where the CHPS Initiative has been operational in the last three years, the purpose in this case, is clearly known and that will inform the choice of the population to be sampled, which were communities that fall within the various CHPS zones. The Community Health Officers (CHOs) within the five (5) functional CHPS zones would be purposively selected as well as the Sub-District Health Team (SDHT), this is because they are considered knowledgeable about CHPS and very vital in its success.
Simple random sampling will be used to select the functional CHPS zones that would be covered by the study, in all there are ten (10) functional CHPS zones in the Lawra District five (5) out of the ten (10) would be selected using this method. Thereby giving all the ten functional CHPS zones in the Lawra District an equal chance of being selected.
The CHPS initiative does not operate on community basis but on the local government structures making use of unit committees (with population of 1500). The recommended population of a CHPS zone is between 3000 and 4500 people, that is, covering up to three unit committees of the District Assembly.
3.4 Sampling Size
In research the rationale is to make generalization or to draw inferences based on samples, about the parameters of population from which the samples are taken (Yin, 1993). It is further argued that a study based on a representative sample is often better than one based on a larger sample or interviewing larger number of people saying the same thing.
Based on the above, my choice of sample size would be influenced by the following;
Population size.
The specific population of interest.
In the light of the above, ten (10) communities would be randomly selected from the five (5) functional CHPS zones in the Lawra District, based on the number of households in these selected communities, the number of households that would be used to conduct the household surveys would be determined. The distribution of the households to the communities would be based on the population size of each community.
The actual sample size would be determined using the mathematical approach;
n= N
1+N (α²)
Where n is the sample size
N is the total population (households) and (a) is the error margin (5%)
3.5 Data Collection
Both primary and secondary data would be gathered for the purposes of the study. Primary data would be gathered through the administration of questionnaires for personal household interviews, interview guides for discussions would be held with key informants in rural communities in the Lawra District. The household questionnaires will be used to collect information on those who are present at the time of the interview.
Secondary data would be gathered from sources such as health reports and policy documents, journals, unpublished Bachelors and Masters theses, District Medium-Term Development Plan, annual District Health Reports, as well as other publications sourced from libraries, institutions and the Internet.
3.6 Data Analysis Technique
Both qualitative and quantitative techniques of data processing would be employed in the analysis of data collected. The quantitative data will be analysed using statistical measures/tools such as tables and averages and the Statistical Package for Social Sciences (SPSS) for data processing.
Qualitative data would be edited and analysed, at the same time during the data collection process and after the overall data is collected, so as to detect and eliminate likely sources of error to make the data reliable. The qualitative data would serve as a complement to the quantitative data.
