Population Briefs | September 2005, Vol. 11, No. 3 | Expanding a Successful Health Care Initiative

Population Briefs: Reports on Population Council Research

September 2005, Vol. 11, No. 3

Experimental Programs
Expanding a Successful Health Care Initiative

What is the best way to help institutions replace poorly functioning policies and programs with ones that have been shown to work well? “In Ghana, we are taking mechanisms that work for individual behavior change and adapting them for the purpose of policy and program change within institutions,” says Population Council demographer James F. Phillips. Phillips and his Council colleagues are collaborating with the Ghana Health Service to help that organization overcome the gap between research and action.

Community-based Health Planning and Services
The Ghana Community-based Health Planning and Services (CHPS) initiative aims to scale up an innovative approach to delivering primary health care services on a national level. CHPS is implemented in six stages. Currently, 90 of 110 districts are at the first, or planning, stage. Twenty districts have completed all six stages of implementation in one or more district zones. Ministry of Health teams from Burkina Faso, Ethiopia, and Sierra Leone have come to Ghana to observe CHPS in action, as they begin to implement similar nation-wide programs.

CHPS is based on findings from an experimental study conducted by the Navrongo Health Research Center, a Ministry of Health field station in rural northern Ghana. The Navrongo model uses volunteers from the community and paid Community Health Officers (CHOs). The volunteers focus on promoting family planning and reproductive health among men. The CHOs are specially trained nurses who live and work in community-constructed health centers and provide health and family planning services door to door, traveling by motorcycle.

Health care in Ghana generally has been available from fixed-location clinics. But studies have shown that more than 70 percent of all Ghanaians live more than five miles (eight kilometers) from the nearest health care provider.

Contemplating the challenges involved in establishing the CHPS regimen can intimidate local health officials. In addition to the operational complexity of the program, managers are concerned about sustainable funding and about the possibility that removing nurses from familiar locations and posting them in community health centers, often far from their families, will reduce their morale. These apprehensions have led to delays in implementing the program.

Organizational diffusion
Phillips and his colleagues are approaching the obstacles from a number of directions. “Social diffusion is the process of behavior or attitude change that happens among peers through social interaction. We are focusing on organizational diffusion, a process analogous to social diffusion, in which change can occur in institutions through the communication of ideas or the demonstration of new methods,” says Phillips. The researchers have achieved particular success in facilitating connections among peers. They accompany teams of program officials on visits to field demonstration sites—such as one in Ghana’s Nkwanta district—where staff members showcase their progress. Nkwanta is where the Navrongo model was first duplicated. The Nkwanta replication showed that CHPS could be launched in a non-research setting. This success helped to instill a feeling of “ownership” of the program among staff members. Studies of the diffusion of innovations within organizations consistently show that changes brought from the outside are more difficult to incorporate than transformations that arise from within institutions.

But not all staff members can attend field demonstrations. To increase information dissemination to everyone involved in the program, “we also have a journalist, Niagia Santuah, who produces a series of biweekly newsletters about community experiences in implementing the project, known as ‘What Works? What Fails?,’” says Phillips. “We combine this with a CD-ROM, distributed every 90 days by the Ghana Health Service to managers with budgetary authority at the national, regional, and district levels. The CD-ROM has maps of Ghana showing progress with the initiative, policy documents, and video clips.” All of these communications tools help to build consensus among program staff that change is feasible, acceptable, and not as risky as it might seem at first glance.

“Health workers participating in CHPS tend to be strong proponents of the program, alluding to greater autonomy as well as community support for their work and the personal gratification that this generates,” says Frank K. Nyonator, director of the Policy, Planning, Monitoring, and Evaluation division of the Ghana Health Service. Qualitative research suggests that the presence of a fully functioning pilot program in a district can greatly accelerate the district-wide implementation of CHPS. Once services are demonstrated on a small scale, widespread demand for community- based care builds. Positive experiences with the program and a sense of empowerment that comes from making a real difference in people’s lives reduce nurses’ concerns about relocation to another community.

“Small pilot programs should be fully scaled up in as many districts as possible,” says J. Koku Awoonor-Williams of the Ghana Health Service’s Nkwanta Health Development Center. “These pilot programs are becoming catalysts for change throughout Ghana and beyond.”

Sources
Nyonator, Frank K., J. Koku Awoonor-Williams, James F. Phillips, Tanya C. Jones, and Robert A. Miller. 2005. “The Ghana Community-based Health Planning and Services Initiative for scaling up service delivery innovation,” Health Policy and Planning 20(1): 25–34.

Awoonor-Williams, John Koku, Ellie S. Feinglass, Rachel Tobey, Maya N. Vaughan-Smith, Frank K. Nyonator, and Tanya C. Jones. 2004. “Bridging the gap between evidence- based innovation and national health-sector reform in Ghana,” Studies in Family Planning 35(3): 161–177. (PDF) Also issued as Policy Research Division Working Paper no. 191. New York: Population Council. (PDF) (abstract)

Outside funding
United States Agency for International Development

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