GEHIP’s Community-based Primary Healthcare Program
As part of efforts to improve access to healthcare in remote rural
communities, Ghana’s Ministry of Health supported the design and
feasibility testing of community-based healthcare program in a rural
district in northern Ghana between 1994-1996 , and a follow up
plausibility trial from 1996 to 2003 . The results of these studies
showed that community-based primary healthcare improves access to
healthcare, leading to improvements in several maternal and child health
indicators. In response to this evidence, the Ghana Health Service (GHS)
launched the Community-based Health Planning and Services Program (CHPS)
as a national policy in the year 1999 to scale up this successful
initiative nationwide .
However, CHPS nationwide scale-up was constrained by challenges related
to inadequate understanding of its service delivery modalities,
communication deficits, low human resources capacity, lack of material
logistics including funds and leadership bottlenecks . An in-depth
review of the operational constraints to CHPS scale-up by the Ghana’s
Ministry of Health in 2009 provided a set of needs that was used to
inform the design of a project known as the Ghana Essential Health
Interventions Program (GEHIP) to demonstrate practical means of
implementing and scaling up community-based primary healthcare .
The GEHIP project was implemented in a poor remote region of Ghana; the
Upper East Region (UER). This region is located within the Sahelian
savannah ecological belt in the north-eastern part of Ghana. It has a
population of about 1.3 million . It has a poverty prevalence of 55%
and almost 40% of its indigens have no formal education . GEHIP project
was implemented in seven districts in this region with three serving as
intervention districts while four others serving as non-intervention
comparison districts. Both intervention and comparison districts were
purposively selected based on their remote geographic isolation and
socioeconomic deprivation.
GEHIP interventions included training and technical assistance provided
to district-level health managers and frontline community health
workers. These trainings aimed at building their capacity in both
community and stakeholder engagement to support health service delivery
and utilization. The project focused on addressing the challenges of
effectively marshalling the system associated with the management of
existing staff, equipment, pharmaceutical supplies, and leadership
capacity for primary healthcare. Focus was directed to improving the
implementation of the WHO’s six health system building blocks . At the
onset of the GEHIP, there was no shortage of nurses for expanding
community-based healthcare operations in Ghana; but rather, a lack of
health facilities in most communities/villages where trained nurses
could be posted to render services . Also limited was district-level
leadership understanding of strategies for obtaining resources for
constructing and managing community health posts effectively
.
To address these challenges, GEHIP developed a framework for
strengthening community-based primary healthcare. The strategy was
focused on improving district-level leadership capacity, use of
information for decision-making, logistics, and budgeting, health worker
training, and deployment for the provision of healthcare at the
community locations. Specific maternal and child health interventions
were included within GEHIP, including the integrated management of
childhood illness regimen recommended by the WHO . GEHIP also developed
a referral service program that enhanced health facility delivery using
community engagement strategies to improve social support for referral
operations . GEHIP was a plausibility trial in that the introduction of
intervention was configured at the district level, preventing the
imposition of randomized assignment of treatment observational units.
Methods for statistical analysis of non-experimental conditions were
therefore required . In the programmatic context of the Ghana Health
Services (GHS), region-wide
implementation of
some interventions involving health worker training and deployment
program focused on WHO recommendations for caring for the mother and
newborn as well as the integrated management of childhood illness . All
such national program interventions were implemented equivalently in
treatment and comparison districts.
The main objective of this current study is to assess the effect of
GEHIP’s community-based health program on adverse birth outcomes. To
achieve this, we examine; 1) the proportion of adverse birth outcomes
for both intervention and non-intervention districts and the average
treatment effect of GEHIP on birth outcome, 2) assess the distribution
of adverse birth outcomes by wealth index and mother’s educational
attainment for both intervention and non-intervention districts and 3)
examine the equity effect of GEHIP’s community-based healthcare program
on birth outcomes by household wealth index and maternal education.