|
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
AFRICA Innovative Strategies for Bridging Health
Inequality Gaps Santuah Niagia, Population Council, Ghana
Following the World Health Organization–inspired Alma Ata Conference of 1978, which reached a consensus that "health for all” could be achieved by the year 2000, accomplishing “health for all” through village-based primary health care became the official goal of most developing countries. International interest in establishing “health for all” led to regional health agendas, such as the UNICEF-sponsored “Bamako Initiative,” which promoted the idea that managing health care resources and providing revolving funds for primary health care drugs and services through community volunteers can be a sustainable means of achieving “health for all.” Other approaches have emphasized the need for placing paid health workers in communities. A decade after the Alma Ata declaration, two-thirds of all deaths among children under five years, and half of the years of life lost in the sub-Saharan Africa region, were attributable to measles, malaria, diarrheal diseases, and acute respiratory infections, often acting in synergy with malnutrition. By the early 1990s, mounting evidence showed that Ministry of Health (MOH) primary health care coverage for Ghana was low. Modern contraceptive uptake goals, particularly for family planning, were not being met. The maternal mortality rate (MMR) remained at an estimated 600/10000 (Ngom et al. 1999) and under-five mortality in 2000 was 153/1000. Some of the major challenges blocking access to health care included: long distances to health facilities; poor road networks and transportation systems; lack of money to pay for health services; restrictions on women’s access to health services; shortages of trained health staff, exacerbated by the brain drain in the health sector; and inadequate supply of essential service-delivery equipment. Throughout the late 1990s, debate about the relative effectiveness of community volunteer versus community health nurse persisted in Ghana. Community health nurses, who are trained for community work, remained based in sub-district (Level B) clinics that were inaccessible to a large proportion of rural households. Though widely viewed as representing an effective approach to reducing mortality, the feasibility and sustainability of posting community health nurses to live and work in communities is often questioned, with the volunteer approach advocated as a low-cost and sustainable alternative. The Community Health and Family Planning project (CHFP) of the Navrongo Health Research Centre (NHRC) was a direct response to the ongoing debate. The Navrongo Health Research Centre has a mandate from the MOH to investigate health problems of the Sahelian ecological belt of northern Ghana and then advise the Ministry on possible interventions. Armed with experience from the field and with approval and support of the MOH, the research center launched a series of focus-group studies to find out why health-service utilization was low and why family planning uptake, specifically, was not progressing. This was an opportunity to research innovative ways of taking health care to the doorsteps of the people and involving them in the design and delivery of health services. The thinking was that as project consultants, community members had a fair idea about what would work and what would fail. In the focus group discussions, respondents appealed for health care strategies that, in the words of one woman, would “first make sure that our children do not die.” Child survival thus became crucial to the acceptance of family planning. Respondents also wanted service approaches that would respect their concerns about privacy, and women appealed for approaches that would put men at ease about family planning. In keeping with the spirit of “health for all,” the Navrongo Health Research Centre took the next step beyond the focus group studies and developed a package of services to respond to the expressed needs of the people and to test the impact of this health-development program on fertility and child survival. Although there was unanimity on what needed to be done, there was no consensus on how to proceed. Some policymakers advocated retraining, reorienting, and relocating community health nurses in ways that would make community health care a reality. Others were of the opinion that only volunteer services could be affordable and practical. Volunteer services, while representing an appealing concept, had formerly failed to produce satisfactory results. Debate about what to do with poor functioning—in primary health care, community nursing, and village volunteerism—was at the core of the view that an experiment was needed. Specific questions were asked by the Ministry of Health that could not be resolved without evidence from a field trial:
The NHRC launched a program of social research and strategic planning. Contributions from the community consultations were used for designing an experiment that became known as the Community Health and Family Planning Project, or simply “The Navrongo Experiment.” The overall goal of the experiment was to improve the coverage and quality of health care services. Facilities, staff, and medical supplies utilized in the experiment are resources routinely available throughout the experimental region, and all study areas of the district have the same density of health care providers per population, the same level of training, and the same medical supplies. Beginning in 1994 and over the initial 18 months of the project, services were launched in three pilot villages to gauge community reaction and test the cultural suitability and social acceptability of the design. In this manner, social learning, listening, testing, and responding became over time a resource for organizing the experiment. Community response to pilot service delivery was fed into the design of a system of village-based services that were compatible with the social system and sensitive to stated needs. Chiefs, elders, women’s groups, and other community institutions were contacted by project workers and involved in a system of support for community health-service delivery. Community health nurses, who had in the past been assigned to underutilized clinics, were reassigned to village-based community health compounds constructed through communal labor for their use. Discussions continued and services were changed and adapted to community opinion, reactions, and advice. In this way, concerns about promoting the survival of children, addressing the needs expressed by women for family planning, and respecting the concerns of men guided the actual activities of the program as it evolved from a micro pilot. Once the overall system of culturally appropriate care was developed, the experiment was expanded into the entire Kassena-Nankana District in 1996. The experiment tested the effectiveness of alternative strategies for utilizing two broad sets of resources, each defining a dimension of the project:
The Ministry of Health dimension focused on fixed-facility health care delivery, under which essential resources are lacking, community mobilization and supervising systems are weak, and community accountability is rarely developed. Community health nurses who had hitherto been confined to these fixed facilities were retrained and renamed “community health officers” (CHOs). They were reassigned from sub-district clinics to community-constructed residences known as community health compounds and were equipped to conduct door-to-door health services. CHOs are trained for two years and paid a monthly salary, provide a wide range of health intervention options. This approach bridges social distance between service provider and client, thus making the service-delivery atmosphere friendlier. The zurugelu dimension, or volunteer approach, involved constituting health care action committees from existing social networks and supplementing supervisory services with active, traditional village self-help schemes. The services are provided through the use of community health volunteers who are chosen by the community and trained by project staff to provide basic health care services such as reproductive health education, outreach to men, and supplying contraceptives. Outreach to men is undertaken by community gatherings known as durbars, at which discussions focus on health and family planning themes to give men an open forum to discuss their reactions to the program. Since the zurugelu and Ministry of Health dimensions can be mobilized independently, jointly, or not at all, the design suggests a four-cell experiment: Cells of the Community Health and Family Planning Project
Cell I tested the “zurugelu dimension”—the community is mobilized; chiefs, elders, opinion leaders, and social networks are organized in support of a community health committee that supervises community health volunteers. Cell II was reserved for experimenting with the “Ministry of Health dimension”—the nurse/community health officer deployed to live among the people and provide doorstep and compound-specific health care. The third arm of the experiment, Cell III, combines the Ministry of Health nurse outreach services and the zurugelu approaches in which volunteers are selected and trained to actively support the nurse. Cell IV, which had normal Ministry of Health services (without the addition of nurses or volunteers), served as the control. In the combined cell, where the zurugelu and community health officer approaches are pursued simultaneously to test the hypothesis that volunteerism and nurse outreach mobilization, interventions are complementary and synergistic, combining the implicit accountability and sustainability of the volunteer with the relative advantages of professionalism in the nurse. The Community Health and Family Planning Project (CHFP) has been developed and tested in the context of severe poverty and adversity in the Kassena-Nankana District. Kassena-Nankana District is one of 138 political administrative divisions in Ghana. It is situated in the Upper East region, which is the country’s poorest region— nine out of ten people live below the poverty line of less than US$1 a day. Mortality levels in the area remain high, while cultural traditions sustain high fertility. The “State of the Nation” report (2000) indicated that while the national average of infant mortality was 66/1000 live births, that of the Upper East Region was 105/1000 live births. The infant mortality rate (IMR) for the Kassena-Nankana District was 124/1000 in 1995 (Binka et al. 1999) and the maternal mortality rate (MMR) was estimated at 600/10000 (Ngom et al. 1999). Under-five mortality in 2000 was 153/1000 as against the national average of 110/1000 . Geographically, the Kassena-Nankana District shares borders with Burkina Faso to the north, Sissala District to the west, Bolgatanga Districts to the east, and West Mamprussi to the south. Its current population of 150,000 (Ghana Census 2000) inhabits 14,500 compounds that are unevenly spread over 1,675 square kilometers of semi-arid grassland. Subsistence agriculture is the mainstay of the people who battle yearly with a long dry season from October to April and a short rainy season from May to September. The district has one of the highest illiteracy rates in the country, with an illiteracy rate among females of six years and above reaching as high as 62 percent. Traditions of marriage, kinship, and family-building emphasize the economic and security value of large families. Health decision-making is strongly influenced by customary practices, traditional religion, and poverty. The Navrongo Experiment therefore examined policy questions with scientific tools developed for the evaluation of health technologies, permitting precise scientific appraisal of ways to help people in significant need. The feeling of the Ministry of Health was that if an experiment of that nature could work in such inauspicious settings, it had a good chance of working in more favorable conditions in other parts of the country. Contraceptive knowledge and use Community entry, mobilization, and male participation are essential to success. But, zurugelu activities without nurses are also not enough. Women require comprehensive and convenient services, and volunteers distributing a single method did not meet their needs. Putting it all together— with volunteers working closely with nurses, communities mobilized, chiefs and elders on board, social networks organized and health services well developed—family planning can work even in settings where traditions are strong and the role of family planning is debatable. Results also suggest that social interaction about family planning triggers changes in contraceptive behavior. For the majority of the women, the decision to initiate family planning practice is facilitated by informal discussions with social network partners who encourage contraceptive adoption. Generally, community reaction to services has been positive, but it has been observed that some men express concern about the liberating effect family planning services have on women, and some women worry about ostracism and even violence if family planning practice becomes known in the extended family and community. Fertility Where there have been no Community Health and Family Planning Project activities—only normal MOH clinics—fertility declined by a half a birth in 1998, but then returned to baseline levels by 2001. This pattern was also followed in the “nurse only” area, which had even higher fertility throughout the study period. Although the CHFP has induced reproductive change in Kassena-Nankana District, contraceptive use is clearly not the only fertility determinant responsible for fertility declines in the district or the entire upper East region. In 1998, fertility declined markedly in all experimental areas of the district including the comparison area, but the determinants of this change were dominated by abstinence and delayed marriage rather than by increased contraceptive prevalence. So, a general conclusion is evident from the Community Health and Family Planning Project: Despite the inauspicious social and economic context for reproductive change, the CHFP has had an impact on fertility. In rural Ghana, where traditions of chieftaincy, lineage, and consensus-building remain vibrant, outreach to key male leaders and mobilization of their networks can put men at ease about family planning, and can ultimately determine whether or not women can exercise their reproductive preferences. Mortality Unexpectedly, volunteers operating alone had a detrimental effect on childhood mortality. Exposure to the zurugelu or the Bamako-like strategy is associated with an increase in the odds of early childhood mortality by nearly twofold. Children in the second year of life experienced double the mortality rates that they experienced prior to intervention in areas where volunteers alone provided services. The rise in mortality after volunteers were posted could be attributed to the fact that when children become sick, their mothers first consulted the volunteer (as the project intended), whose services were more convenient and less expensive than those of the clinic. As part of their responsibilities, the volunteers were expected to provide basic medicines, and to refer children to a clinic for antibiotic therapy. In the second year of life, acute respiratory infections were an important cause of morbidity and mortality in the district. In such cases, mothers may be receiving ineffective treatment from the volunteer rather than being referred to the clinic, leading to increased mortality among children in this age group. The second possibility is that mothers may not be responding to referrals by the volunteers at all, or in situations where the mothers may heed the referral advice of the volunteers, they may not treat it with the urgency it deserves. CHOs have their impact on health by substituting services for these sources of delay. In cells where CHOs are posted, women have more autonomy in seeking health care for children than in other cells. Through household encounters, children receive prompt treatment that would otherwise require permission. Costs are reduced, and sometimes deferred, permitting families to share costs when resources are available. CHOs substitute modern services for traditional healing, providing a meaningful alternative to traditional care. In contrast, even the most dedicated volunteer lacks the credibility, skills, and services that mothers seek for their children, though their role as family planning promoters among men and their work as facilitators of CHO services are positively influential. The combined cell of the experiment had no apparent effect on late childhood mortality, possibly because CHO effects are offset by the detrimental volunteer effect. The experiment has shown that both nurses and volunteers are respected in communities, but nurses change traditional health-seeking behavior while volunteers do not. Several important features of household health decisionmaking—such as mother’s health-seeking autonomy, home treatment owing to resource constraints, and social customs—can lead to fatal delays in seeking effective care. Results of the Navrongo Experiment thus challenge the assumption by international agencies, policymakers, and health providers that mobilizing community volunteer operations work will improve health. The study indicates that the community health compound, a one-stop health service delivery post at the community level, has become the symbol of efficient health care delivery in rural settings. A trained CHO, equipped with a motorbike, basic drugs, and equipment for primary health care, is redeployed from a sub-district clinic to the community. When it comes to building a dwelling place for the redeployed nurse, resources can be mobilized locally, and health committees can coordinate the process. Health committees can support the work of nurses, and drugs can be maintained at the community health compound. By putting the community health committee in charge of supervising community-based health care, and with health volunteers playing the role of social mobilizers, what usually works always works. But when volunteers are involved in care giving and drugs management, what usually works sometimes fails. National In October 1999, the Ministry of Health developed the Community-based Health Planning and Services (CHPS) project, a nationwide initiative for improving coverage and utilization of health service for underserved populations. Since then, enthusiasm for community-based care has grown, and in many districts in the country this has translated into successful action. International In October 2004, a six-member delegation from the high echelons of the Ministry of Health of Burkina Faso, Ghana’s northern neighbor, held consultative meetings with the Ghana Health Service and the MOH on ways to promote the replication of the Navrongo Experiment. There is now talk of “CHPS Without Borders” and “The Exchange,” which seek feasible means of sharing experiences on community-based health service operations and creating space for promoting the replication of CHPS for people in extreme poverty or emerging from political crisis. Today, “health for all” is becoming reality in Kassena-Nankana district. Community health nurses have been retrained, reoriented, rechristened “community health officers,” and redeployed to live in rural locations to provide close-to-client health care. This model of doorstep health provision improves geographical access, reduces cost for the client, and bridges social distance, thus improving the overall quality and user-friendliness of health services for the most needy. Results of the Community Health and Family Planning experiment, has shown that providing the services of a community-resident nurse in the context of mobilized support from community leadership and networks represents an important, innovative step toward increasing health service coverage and utilization. Ghana has thus taken the lead in developing a feasible model for achieving the United Nations Millennium Development Goals. This model holds promise for international application. Related Projects See Also Offsite Links
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
