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October 2007, Vol. 13, No. 2Poverty, Gender, and
Youth
Two
strategies for delivering care The program was conducted in four geographic regions in Kassena-Nankana District. People in Area 1 were exposed to the zurugelu strategy alone. Residents of Area 2 received care from nurses alone. In Area 3, people had contact with both the zurugelu and nurse-outreach strategies. In these three experimental areas as well as in Area 4, a comparison area, residents had access to Ministry of Health fixed-location clinics. These clinics, however, can be distant and hard to reach. The lives of people in this program were tracked with the Navrongo Demographic Surveillance System. “This powerful tool, a computer program, registers all demographic events—including births, deaths, major illnesses, educational attainment, migrations, marriages, and pregnancies—that occur in the lives of all 142,000 individuals residing in Kassena-Nankana District,” says Ayaga A. Bawah, a research fellow at the Navrongo Health Research Centre. When the research center was founded in 1992, mortality rates in the area were well above national levels in Ghana. When children became sick, parents usually sought out traditional healers rather than modern health care options. Analysis of the early results of the program produced the astonishing result that in the zurugelu and nurse-plus-zurugelu arms of the study, child mortality was actually increasing, compared with mortality before the intervention. In contrast, the nurse-only and comparison areas saw decreased child mortality. An early meeting of researchers pinpointed the problem. Volunteers had been allowed to distribute fever-reducing liquid medicines for infants and small children, similar to Tylenol®. Villagers believed these medicines to be actual curative treatments, and thus delayed seeking medical care for their sick children. Once these medicines were removed from the volunteers’ toolkit, child mortality returned to its previous levels. “We’ve found that, in the long run, volunteers provide no effect, either detrimental or beneficial, in terms of child survival, as long as they are not providing anti-fever medicines,” said Population Council demographer James F. Phillips, a senior technical advisor to Ghana’s Community-based Health Planning and Services Project. “Volunteers do help to reduce fertility, however, by reaching men with family planning advice.” On average, total fertility rates in Area 3, where people had contact with both nurses and volunteers, were one birth less than expected if there had been no intervention. The results from Navrongo strongly challenge the rationale for volunteer-based health programs designed to improve child survival. Instead, the data suggest that convenient, accessible professional nursing care can reduce child mortality in impoverished African settings. “This happens because people begin to seek nurses, who can provide preventive and curative health care, rather than traditional healers,” explains Fred N. Binka, executive director of the INDEPTH Network (an international network of field sites with continuous demographic evaluation of populations and their health in developing countries), and former director of the Navrongo Health Research Centre. The addition of community volunteers to the mix has no impact on child mortality, in part because volunteers cannot offer antibiotic therapy and in part because volunteers lack sufficient credibility to supplant traditional health-seeking behavior. “However, volunteers can reach men in the community with new ideas about family planning,” says Binka.
Community-based health planning and services Additionally, the Population Council has received assistance from USAID to help scale up the implementation of CHPS in 30 deprived districts in seven regions in southern Ghana. The project has improved the service delivery skills of community health officers as well as the managerial skills of their supervisors. Motorbikes, bicycles, and medical equipment, such as scales and refrigerators for vaccines, have been distributed to 60 community health compounds to improve the quality of service delivery. The Council has succeeded in increasing support for the CHPS program among members of the District Assembly, an important factor in the successful expansion of the program. Sources Pence, Brian Wells, Philomena Nyarko, James F. Phillips, and Cornelius Debpuur. 2007. “The effect of community nurses and health volunteers on child mortality: The Navrongo Community Health and Family Planning Project.” Scandinavian Journal of Public Health. Epub 22 June 2007. Bawah, Ayaga A., James F. Phillips, Martin Adjuik, Maya Vaughan-Smith, Bruce MacLeod, and Fred N. Binka. 2006. “The impact of immunization on the association between poverty and child survival: Evidence from Kassena-Nankana district of Northern Ghana,” Policy Research Division Working Paper no. 218. New York: Population Council. (abstract) (PDF) Outside funding Related Projects
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