University of Ghana http://ugspace.ug.edu.gh RA552.G5Az9 bite C.l G368250 University of Ghana http://ugspace.ug.edu.gh COMMUNITY PARTICIPATION IN THE COMMUNITY- BASED HEALTH PLANNING AND SERVICES (CHPS) PROGRAMME IN NKWANTA DISTRICT, VOLTA REGION, GHANA A DISSERTATION SUBMITTED BY THOMAS BAVO AZONGO TO THE SCHOOL OF PUBLIC HEALTH UNIVERSITY OF GHANA LEGON IN PARTIAL FULFILMENT OF REQUIREMENTS FOR THE AWARD OF MASTER OF PUBLIC HEALTH (MPH) DEGREE AUGUST 2002. University of Ghana http://ugspace.ug.edu.gh 1 D E C LA R A TIO N This d issertation is the result o f m y independent investigation. I have m ade acknow ledgem ent, w here m y w ork is indebted to the w ork o f others. I declare that, this piece o f w ork has not been accepted in substance for o ther degree, nor is it concurrently being subm itted in candidature for any degree. THOM AS B A V O AZON G O A CA D EM IC SU PER V ISO R S: l ..... ....................... PROF. ISABELLA QUAKYI DR. G L O tfjA Q t JANS AH A SA RE University of Ghana http://ugspace.ug.edu.gh ii D E D IC A T IO N I dedicate this piece o f w ork to m y children [Lydia N yab-m a, de-K lerk N yaba and Henry Sapark] for m issing m e during m y m any years o f schooling. University of Ghana http://ugspace.ug.edu.gh G LO SSA R Y OF A BB REV IA TIO N S 1. C H P S ......................................C om m unity-based H ealth P lanning and Services. 2. C H F PP ....................................C om m unity H ealth and F am ily P lanning Program m e. 3. C H O ........................................ C om m unity H ealth Officer. 4. C H N ..........................................C om m unity H ealth N urse 5. C H C ...........................................C om m unity H ealth Com pound 6. C H V ...........................................C om m unity H ealth V olunteer 7. D D H S ...................................... D istrict D irector o f H ealth Services 8. D H M T ......................................D istrict H ealth M anagem ent Team 9. F G D ...........................................Focus Group D iscussion 10. M O H ...........................................M inistry o f H ealth 11. N H R C ................................. N avrongo H ealth R esearch Centre 12. P H C ...........................................Prim ary H ealth Care 13. S D H T ...................................... Sub-D istrict H ealth Tearn 14. W A T SA N ............................ W ater and Sanitation C om m ittee 15. W H O ...................................... W orld H ealth O rganization University of Ghana http://ugspace.ug.edu.gh TA B LE OF CO N TEN T Page number D eclaration 1 Dedication 11 Glossary o f abbreviations iii Table o f content *v A cknow ledgm ent V1 Abstract C H A PTER O NE 1.1 Introduction 1 1.2 Background to the study area 3 1.3 Statem ent o f the problem 8 1.4 O bjectives o f the study 10 C H A PTER TW O Literature R eview 11 CH A PTER TH R E E M ETH O D O LO G Y 3.1 Study D esign 18 3.2 M ethods o f D ata C ollection 18 3.3 Sam pling P rocedure 19 3.4 Com m unity entry/ E thical clearance 20 3.5 Data processing and A nalysis 21 3.6 Lim itations o f the Study 23 CH A PTER FO U R FIN D IN G S/RESU LTS 4.1 Basic C haracteristics o f R espondent/ participants 24 4.2 A ssessm ent Results 4.21 N eeds A ssessm ent 25 4.22 Leadership 28 4 .230rganisation 31 4.24 M anagem ent 32 4.25 Resource M obilization 33 CH A PTER FIVE C O N CLU SIO N AND R EC O M M EN D A TIO N S 5.1 Conclusion 36 5.2 Recom m endations 36 5.21 The CHOs 37 5.22 The Health V olunteers 39 5.23 Tutukpenc Health Center 39 University of Ghana http://ugspace.ug.edu.gh V 5.24 C osting and Evaluating C om m unity Contributions 40 5.25 Inter-sectoral C ollaboration 40 5.26 A dopting CH PS in the D istricts 40 5.27 Surveillance 41 R EFER EN C ES 42 A PPEN D IX 44 University of Ghana http://ugspace.ug.edu.gh VI A C K N O W LED G EM EN T This w ork has been successful due to the im m erse contributions o f m any persons and organizations to w hom I ow e a great deal o f gratitude. I am particu larly indebted to the following: 1. The School o f Public H ealth- for the good training I received to be a Public H ealth Practitioner. 2. The U niversity for D evelopm ent Studies (UD S)- for the sponsorship given to m e to pursue the M PH course. 3. M y supervisors. P rofessor Isabella Q uakyi and Dr. G loria Q uansah A sare have been m y A cadem ic advisors. T hey have guided m e in w riting up this dissertation. A lso their painstaking reading and corrections in the w rite up has been o f im m erse benefit. Dr. K oku A w oonor-W illiam s offered invaluable guidance and support during m y fieldwork. H e w as not ju s t m y field supervisor but also an inspirer w ith good leadership qualities, v ision and initiative that I aspire to em ulate. 4. The entire s ta ff o f the N kw anta D H M T. Particularly M r. C onstant D edo and M iss G ifty Sunu who offered m e assistance in D ata collection. 5. The chiefs, elders, A ssem blym en, m en and w om en o f all the CHPS zones in N kw anta district for the patience and cooperation I enjoyed from them during the period o f data collection. 6. All the C om m unity H ealth O fficers- for helping me to organize the focus group discussions and interviews in their operational areas. It is with deep sense o f appreciation that I acknow ledge the contributions o f all these and m any others in this enterprise. I can only pray that the A lm ighty God richly bless them all. University of Ghana http://ugspace.ug.edu.gh vii A B ST R A C T The m ain strategy used in the Com m unity-based H ealth P lanning and Services (CH PS) initiative in G hana has been the incorporation o f com m unity partic ipation in the planning and delivery o f basic Prim ary H ealth Care services. A ccord ing ly the thrust has been on tw o m ain processes: m obilization and reorientation o f the health care system as w ell as m obilization o f the traditional society and social system s w ithin w hich the program m e operates. The CHPS program m e has been adopted and is being im plem ented in the N kw anta district for four years now. R apid assessm ents indicate som e positive results in health status indicators o f the people. An in-depth assessm ent o f the tw o m ain processes has becom e im perative. W hile the D H M T tried to evaluate its ow n perform ance in m obilizing the health care system , this study also tried to concurrently assess the com m unities’ participation , w ith the hope that this w ould com plem ent efforts to achieve a com bined resu lt that w ill o ffer a sense o f d irection and sustainability o f the program m e. M ethodology used in this study involved m ainly qualitative techniques such as Focus Group D iscussions w ith com m unity opinion leaders; in-depth interview s w ith care providers and in-depth interview s w ith adm inistrative m anagers o f the program m e. The Focus G roup D iscussions w ere done in all the six CHPS zones. V iew s on the level and kinds o f com m unity support and involvem ent in the program m e w ere solicited. A nalysis w as based on them es that centred on the five com ponents o f the Rifkin M odel for assessing com m unity participation: N eeds assessm ent, Leadership, organization, R esource m obilization and M anagement. University of Ghana http://ugspace.ug.edu.gh Findings indicate that involvem ent o f the com m unity m em bers in the planning, im plem entation and evaluation o f program m e activities has been high. T heir in-kind support has been the m ain m otivation for the direct service providers (i.e. the C om m unity Health O fficers) to continue to stay and w ork w ith the people. The people are generally satisfied w orking w ith the program m e m anagers and som e N G O s as their m ain source o f cash flows and teclm ical support w hile dem onstrating a sense o f ownership for the program m e and feeling they equally contribute to its operation and sustainability. H ow ever, how long the often-overw orked care providers w ould continue to be m otivated by the com m unities’ m odest support system s is o f great concern to com m unity m em bers them selves as w ell as to the program m e m anagers. It is recom m ended that steps be taken to explore w orkable m echanism s to sustain the self-help and self-reliant spirit o f the people as w ell as w orkable m otivational packages for the care providers. C om m unity enthusiasm for CH PS provides the possibility o f developing com m unity “hospitals” at least in N kw anta district. This could be intim ation that hospitals per se w ould not continue to be the ultim ate m eans o f acquiring health care in rural com m unities. As such the steps taken by governm ent and the M OH/GHS to im plem ent CHPS in other parts o f G hana is in the right direction. University of Ghana http://ugspace.ug.edu.gh .x-: -XV.-:--r SP.Vv; ' ‘ .• DISTRICT M A P Uh bf lANA u m - ’oa 1*00' . . VtSL. OO' fo o ' P U R K t H i F A S O I: I- 1 Toe . 1 . _ ^ Zcbl^ L E G E N D y . A , _+ • 4-■ * - ^K Bou"xia f y boi&aun&Awc — ---------- -----R t g lo r o l E o tn d c r L , ~ \ S ^ A < * # Gvr^c;a Qitricl B0ir»cW; © _ _ _ K o h c ro t Cepifol C? “ _____ Regional Copilal f • O i i l f ic t Copitot 1 Of s 00 • Orcwn- by: E.O.HiHf T1 M1 ♦ 9Q_ University of Ghana http://ugspace.ug.edu.gh NKWANTA S U B - D IS T R IC T S OF H E A L T H 30 30 30‘ 30 ' University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE 1.1 INTRO DUCTIO N In trying to achieve the policy goal o f providing adequate, efficient and equitable Primary Health Care services to all Ghanaians, in the face o f dwindling human and material resources, the M inistry o f Health has had to develop innovative and pragm atic health intervention strategies. One such strategy is the Com m unity-based Health Planning and Services (CHPS) programme, a package o f rural health care system developed out o f the experiences o f the Com m unity Health and Family Planning Programm e (CHFPP) at the Navrongo Health Research Center in the Upper-east region. The Kassena-Nankana District in the Upper-east region has been the pioneering district in the experim entation o f the approach while N kwanta district has been playing a leading role in adopting and implementing the approach. CHPS is a process o f strategic planning and implem entation o f Prim ary Health Care activities within a com m unity with the full involvem ent and participation o f the community members. It is a process that emphasizes preventive health care and education through effective com m unication and com munity mobilization. The main activities include: 1. A situation analysis o f health care delivery w ithin a given com m unity 2. Com munity consultation on health needs and prioritization o f such needs 3. Identifying and mobilizing resources both w ithin and outside the com m unity 4. Designing a culturally appropriate service delivery package University of Ghana http://ugspace.ug.edu.gh 2 5. Providing health and family planning services to com m unity m em bers on an individual and household basis and 6. Conducting early diagnosis and treatment o f com m on ailm ents and tim ely referral o f serious cases. The key players in this process are: ■ Com m unity H ealth N urses (re-designated as Com m unity H ealth O fficers {CHOs}) reoriented in outreach service delivery, com munity entry and m obilization. They live in the com m unities to provide health care and fam ily planning services ■ Com m unity H ealth V olunteers (CHV) who carry out dissem ination o f basic health and family planning inform ation and services w ithin com m unities and com pounds com plem entarity w ith the CHOs ■ Com m unity H ealth Com m ittees who manage and guide the health volunteers and also provide traditional authorization and advocacy to the process, and ■ District H ealth M anagem ent Teams (DHM Ts) and the Sub- D istrict H ealth Teams (SDHTs) that provide logistics, training, m onitoring and supervisory support. This study is focused on assessing the role o f community involvem ent and participation in the CHPS process after four years o f its implementation in the N kw anta district o f the Volta region o f Ghana. The assessment was done using a m odified Rifkin model. It is envisaged that the results o f this study will complement that o f a concurrent study by the University of Ghana http://ugspace.ug.edu.gh 3 DHM T aimed at assessing the perform ance o f the DHM T itself, in providing additional information on the mom entum and direction o f the CHPS process in the N kw anta district. 1.2 B A C K G R O U N D TO T H E STU D Y A R EA LOCATION Nkwanta district is the largest and the m ost deprived o f the twelve adm inistrative districts in the Volta region, occupying the northeastern part o f Ghana and at the northern part o f the Volta region. It is boarded to the east by the Republic o f Togo, to the N orth by the Northern region, Kete-Krachi district to the W est and Kadjebi district to the south. CLIMATE Nkwanta district is situated in the semi-equatorial climate region. The climate is characterised by a rainy season from M ay to September and a Dry season from N ovem ber to February. The annual rainfall varies from 1500-1750mm to l250- 1500 m m in the North with average tem perature varying from 25 oC in M arch/April to 24 oC in July. SOCIO-DEM OGRAGHY Nkwanta is a typical rural area with a population o f 152,293 inhabitants (2000 Ghana Population and Housing Census), (but head count conducted by the DHM T in 1999 gave the district a population o f 187,221), with an annual growth rate o f 1.8% and a population density o f 25 inhabitants per square kilom eters. The main centers are Nkwanta, Kpassa, Damanko and Brewaniase, which are also the market centres in the district. The district is University of Ghana http://ugspace.ug.edu.gh 4 divided into 5 sub-districts nam ely Nkwanta, Tutukpenne, Kpassa, Damanko and Breweniase sub-districts. The ethnic com position is highly varied. The Konkombas, Kotokolis, Basares and the Kabres are predom inant in the northern part, concentrating m ainly around Kpassa and Damanko. The southern part is com posed o f the N trobos, who are m ainly in and around Breweniase. The A twodes, Adeles, Challas and Ewes tend to occupy the central part that is, Nkwanta town. This pattern tends to give a fairly ethnic hom ogeneity in the 217 communities in the district. O ther tribes like the Ewes, Krachi, Loso, N aw iris, Chokosis and Fulanis tend to spread across the entire district. TRANSPORT AND COM M UNICATION. Transport and telecom m unications systems are poorly developed in the district. The main road from Kajebi through N kw anta to Damanko is in very bad state, yet this road carries intensive traffic often w ith seriously overloaded trucks between the N orthern region and the south. The hilly nature o f the hinterlands makes the m inor roads leading to these areas even more unmotorable, w ith some communities becom ing inaccessible during the rainy seasons. Telecom m unication system is virtually non-existent except a few Motorola services in some governm ent offices including the DHMT. Mails are brought via any reliable Hohoe-Nkwanta vehicle once a week. University of Ghana http://ugspace.ug.edu.gh 5 AGRICULTURE O ver 75% o f the population is involved in subsistence farming activities but the district is also an important production area for crops like yam, sheanut and groundnut. Citrus, palm fruits, cassava and plantation are also grown but not in com mercial quantities. Gari processing is also com mon. O ther crops grown are rice, beans, com and coco yam. Small- scale fishing is widely practiced along the rivers and lakeside. HEALTH There are insufficient refuse disposal facilities. Public latrines are few even in the urban centres. Indiscriminate defecation in the bush at the outskirts o f the towns is most prevalent. Uncontrolled refuse dumping is generally practised and the lack o f sta ff o f the Environmental Health D ivision makes supervision alm ost non-existent. M any o f the refuse dumps in the urban areas are not well maintained, nor incinerated, not fenced and are located too close to houses and rivers, posing a serious Public health threat. Indeed a study carried out by the DHM T in 1997 showed that a large population o f schoolchildren in the district especially N kw anta township w ere infested with different types o f tapeworm especially taenia and hymenolepsis nana. However environm ental sanitation in the rural communities appears to be better than that in the urban settlements. The entire district has no pipe-bom e w ater system. The traditional sources o f water are rivers, streams and ponds around the town and in the dry season the quality and quantity University of Ghana http://ugspace.ug.edu.gh 6 deteriorate drastically. G uinea worm infestation poses a serious health problem causing a lot o f disabilities and absenteeism from work. The Volta Lake is an im portant source o f water for the villages along its shores, but Bilharzia is a serious threat to the people’s health. DANIDA, an active NGO in the area has tried to provide boreholes to some communities but this only w orks out to approxim ately one borehole per 15,000 people, leaving more than 60 % o f the people w ithout access to safe drinking water. On the average, about ten people live in one house and m ost houses have 3-5 sm all rooms posing overcrowding problem s. About 90% o f the buildings are constructed w ith m ud and roofed with thatch. In the larger towns a few concrete buildings w ith iron sheet roofing are present but most o f these are public or government buildings. There are 20 health facilities in the district o f which 70 % are governm ent-run including the CHPS zones, and the rem aining 30% M ission or private-run. N otable am ong these is the Nkwanta Governm ent hospital where the only governm ent doctor resides, and the St. Joseph’s Clinic at N kw anta where occasionally one or two expatriate doctors com e to work. With the introduction o f the CHPS concept in the past four years the CHPS zone are now the main health facilities for most o f the com m unities in the hinterlands. Out o f the 17 Community Health N urses in the district six are used for the CHPS programme, one stationed in each CHPS zone. These six nurses together provide com prehensive Primary Health Care to 23.2 percent o f the people in the district (occupying 42 o f the 217 University of Ghana http://ugspace.ug.edu.gh 7 com munities in the district) who otherwise would not have had access to any health facility. Plans are underway to create five more CHPS zones, which will cater for an additional 15.1 percent o f the people in the district, occupying 19 communities. Population distribution o f the CHPS zones in Nkwanta district (2002) CHPS zone Population No of % of sub­ % of Sub­ communities district district district Bonakye 6880 8 14.6 4.6 Kpassa Keri 4936 5 14.3 3.3 N kwanta Nyambong 6145 6 17.9 4.1 Kecheibi 5041 8 34.4 3.4 Tutukpene Bontibor 5749 7 25.1 3.9 Brewaniase Obanda 5749 10 25.1 3.9 Total 34500 42 23.2 Population distribution o f the proposed CHPS zones CHPS Population No of % of % of district Sub-district zone communities sub district Sibi 7909 3 27.0 5.3 Damanko Agou-fie 4556 4 9.7 3.1 Kpassa Azua 4919 5 10.5 3.3 Kpassa Chaiso 1564 3 4.5 1.1 Nkwanta Alukpatsa 3391 4 23.1 2.3 Tutukpene Total 22339 19 15.1 University of Ghana http://ugspace.ug.edu.gh 8 1.3 STATEM ENT OF THE PRO BLEM Effective and sustained involvem ent and participation o f com m unity m embers is crucial for the success and sustainability o f any community-based health intervention programme. In view o f this several activities were undertaken, with huge cost in time and resources, to first ensure the cooperation and authorization o f the people themselves at the com munity level before the im plem entation o f the CHPS programme. The CHPS program m e in N kwanta involves two main processes aimed at bringing health closer to the people: m obilizing the health care service system and m obilizing the traditional society and social systems. As part o f activities to sustain the CHPS process the Nkwanta DHM T planned to initiate studies to assess and evaluate its operations. The DHMT wants to first assess its own performance, as the main key players in m obilizing the team, to enable it have a sense o f the extent to which it is contributing to the process. To com plem ent the efforts o f the DHM T this study is done sim ultaneously to assess the other key player (the com munity) in order to determine how far m obilizing the people has been achieved. It is hoped that the combined result o f the two studies will provide relevant information about the progress and direction, and hence a sense o f the sustainability o f the CHPS programme Some preliminary surveys carried out by the DHM T (Annual Report, 2000) on the impact o f the operation have revealed some encouraging results: imm unization coverage in the district was the lowest in the region before the adoption o f the CHPS programme. However the adoption o f CHPS (1997-1999) led to significant increases in coverage for the vaccine- University of Ghana http://ugspace.ug.edu.gh 9 preventable diseases. From 1996-1999 BCG increased from 30.5 percent to 60.0 percent; measles from 27.7 to 48.1 percent and DPT from 18.6 to 37.0 percent. During that period reported cases o f measles reduced from 130 to 42 cases. But how far can we attribute these achievements to the com m unities’ own effort? To what extent can we rely on the continued support and cooperation o f the com m unities for the continued existence and operation o f the CHPS programme especially when funding from DANIDA, W orld Vision and the District Assembly dwindles or winds up completely? W hat is the contribution o f individual com munity members, and to what extent do they take part in decision-m aking? To what extent do the com munities see the program m e to be their own? These, am ong others, are important questions the managers o f the program m e and other stakeholders w ould w ant to ask and find answers to. It is in the light o f these pertinent questions that an assessment o f the level o f com munity participation and involvem ent is crucial and imperative. University of Ghana http://ugspace.ug.edu.gh 10 1.4 OBJECTIVES OF THE STUDY BROAD OBJECTIVE To assess com m unity participation (using the Rifkin M ethod) in the CHPS program m e in the Nkwanta district SPECIFIC OBJECTIVES 1. To determine the extent o f community participation in the CHPS process using the following factors: • Needs assessm ent • Leadership • Organization • Resource m obilization • M anagement 2. To make recom m endations that would im prove and sustain com m unity participation in the CHPS process. University of Ghana http://ugspace.ug.edu.gh 11 CH APTER TW O LITERATURE REVIEW There are two m ajor conceptual and practical difficulties that underline attem pts to define and interpret com m unity participation. These concern the terms “com m unity” and “participation” in their separate entities. Definitions o f com m unity in the literature range from “a group o f people living in a particular area having shared values, cultural patterns and social problem s” (Agudelo, 1983), to “a group o f people distinguished by their shared interest” (M idgley, 1986) and community being target populations or “at risk” groups o f people (Rifkin et al, 1988). Participation has also been defined variously by various authorities, but three characteristic which all the definitions have in com mon have emerged: participation should be active; participation should involve choice with individuals having the right, responsibility and power over decisions w hich affect their living; and that this choice m ust have the possibility o f being effective whereby m echanism s are either in place or can be created to allow this choice to be im plem ented. Bermejo and Bekui (1993) have defined com m unity participation as “ . . .a process whereby specific groups, living in a defined geographic area and interacting w ith each other, actively identify their needs and take decisions to meet them .” A ccording to A tim (2000) community participation m eans substantively involving local people in the selection, design, planning and implementation o f programmes and projects that will affect them, University of Ghana http://ugspace.ug.edu.gh 12 thus ensuring that local perceptions, attitudes, values and knowledge are taken into account as fully and as soon as possible. Susan Rifkin [1988] , who has carried out a great deal o f research on com munity participation, offers a definition that is m ost often cited in the literature. A ccording to her community participation “is a social process whereby specific groups w ith shared living needs in a defined geographical area actively pursue identification o f their needs, take decisions and establish mechanism s to m eet these needs” . The M inistry o f H ealth in Ghana sees com m unity participation as a process o f initiating dialogue w ith various m em bers o f a particular com m unity in a structured m anner with the view to genuinely consulting them as equals in a programme o f activities that aim at building a team between program m e managers and com munity m em bers to jointly understand health problem s in the community, to find solutions to such problem s and to act to solve these problem s using as much hum an and material resources as possible from the community (MOH, GHANA, 1997) . Thus in the Activity Sequence (contained in the CHPS implem entation G uide for District Health M anagement Teams) certain activities are demanded the perform ance o f which is meant to promote com munity participation. These activities include the following: • D ialogue with com munity leadership leading to community leaders acceptance. • Com munity information durbar leading to informed community. • Selection and reorientation o f com munity health committees University of Ghana http://ugspace.ug.edu.gh 13 • Com pilation o f com m unity profile • Durbar to launch the CHO • Selection/training o f Com m unity Health Volunteers. • Durbar to launch the CHVs • Approval o f CH V by the community. In Ghana, attempts have been made at promoting com m unity involvem ent and participation in Primary Health Care. These include the Danfa Rural Health Project (DANFA, 1979), the Brong Ahafo Rural Integrated Development Programme (BARIDEP, 1978) the Ashanti Akim Rural Health Program m e (1979), the Guinea W orm Eradication Programme, Nkoranza Com m unity Health Insurance Scheme, Akyemfo Sanitation Project, M obile Community Clinic. O thers include the Community-directed Treatm ent for Onchocerciasis and lymphatic filiariasis w ith Ivermectin, and the Dangbe-W est Health Insurance Scheme. All these projects concluded that the active involvem ent and participation o f the communities in the provision o f essential health care led to the solution o f several health problems at he local level. For the purpose o f this study community participation m ay be defined as the active involvement o f com m unity m em bers in the identification o f their needs, the m obilization o f local resources and local implementation o f plans to satisfy local needs including health related programmes that promote their welfare. University of Ghana http://ugspace.ug.edu.gh 14 Rifkin et al (1988) suggested a series o f five key indicators that could be applied to the district level in order to assess their potential involvem ent in any health program m e. The use o f qualitative indicators will tell us in any specific programme whether participation has become narrower, broader or remained unchanged. The five factors influencing the process o f participation are identified as: ■ Needs A ssessm ent ■ Leadership ■ Organization ■ Resource m obilization and ■ Management. From each o f these factors a continuum is developed (each one radiating from the same point) with wide participation at one extremity, and narrow participation w here the continuum meets. Each continuum is then divided into a series o f points and a m ark is placed on each one that m ost closely describes participation (by the five factors) in the health programme. These m arks are then connected in a spoke configuration. In this way it can be shown the degree o f breath o f participation to describe a baseline, w hich provides for comparative assessm ent either at a later date or by other assessors. Laleman, et al (1993) used this approach in the assessm ent o f com m unity participation in the Community-based Health Programme (CBHP) in the M unoz-com m unity in the Philippines. Retrospective analysis o f the programme revealed very clearly that the absence o f a needs assessment with people was a m ajor obstacle for the developm ent o f a community-based process. It illustrated also that a special effort should be made to build on University of Ghana http://ugspace.ug.edu.gh 15 existing organizations. These usually have their own fora for dialogue and discussion, offer the possibility o f incorporating the health program m e into existing structures and provide several opportunities to find durable solution for the problem s o f leadership, organization, resource m obilization and management. All the people involved in the M unoz programme wanted to go beyond the scope o f merely providing some medico-technical interventions thus involvement o f the population in the planning, im plem entation and evaluation o f the activities was a m ajor objective. Laleman et al [1993] concluded that while this analytical approach does not aim to produce an objective and quantitative m easurem ent o f a particular situation, it does provide a common language for the different observers and makes it possible to pinpoint and describe the dynam ics o f the com plex field o f assessing community involvement. Schmidt et al (1996) in their study described an experience w here D istrict Health Programme sta ff used the Rifkin m ethod to assess the current com m unity participation in their programme in Tanzania. Their findings/conclusions are sum m arized as follows: ■ Needs Assessment: Needs assessm ent was placed on point 5 o f the continuum. The inform ation taken from the interviews pointed to the fact that, in general, the m ajority o f the village was involved in the assessm ent o f the needs. ■ Leadership: University of Ghana http://ugspace.ug.edu.gh 16 Leadership was considered restricted, remaining at point 1 on the pentagram . It was perceived that the village leader made almost every decision by h im self without consulting the different councils o f the village. ■ Organization: Organization was placed on point 2. The conclusion o f the assessm ent was that the VHC was a creation o f the family Health programme rather than o f the village people. ■ Resource m obilization: This was placed at 3 on the continuum. ■ Management: M anagement w as seen as restricted. This ranking was based on the finding that the VHC was rarely involved in the supervision o f the Village H ealth W orkers (VHW s). Officials rather than village-based organizations or individuals carried out this task. In general the Schm idt et al [1993] study showed that the Rifkin M ethod is not only a valuable tool contributing to the management o f district health program m es but it also provides stim ulation to program m e staff to investigate and seek support for com munity participation at the local level. Lessons learned from the Navrongo Community Health and Fam ily Planning project (NHRC, 1998) offers a good guide to the CHPS process in the N kw anta District. The "Zurugelu A pproach” (mobilising traditional social institutions for PHC) dem onstrated that mechanisms for traditional governance and group action could be utilised for communicating with com m unities to achieve community participation. Liaison with chiefs, University of Ghana http://ugspace.ug.edu.gh 17 elders and lineage heads and the co-operation with village peer networks and group leaders can legitimise and explain family planning to men. Durbars are particularly useful for health education and family planning. Chiefs, elders and com munity leaders welcome dialogue with MOH staff and seek regular exchanges and hence a regular program m e o f com munity dialogue and exchange should be part o f every DHM T programme. The YZ (Yezura Zenna, Health Representative) has proved that volunteerism can be an important resource in the implementation o f MOH PHC programmes (NHRC, 1998). The YZ (Health Representative) is a new and effective volunteer cadre in the CHFPP in Navrongo. Sim ilarly there is a good spirit o f volunteerism in the CHPS process in Nkwanta. Every CHPS zone has one or two volunteers who help the CHO in her day-to- day activities. These w ere selected by the com m unities, trained by the DHM T and inaugurated at durbar organised for such purpose. Another lesson from the scaling up o f the Navrongo Experim ent is that com m unities will donate labour for the construction o f CHC, promote health services in durbars, and welcome family planning activities. However seeking cash outlays for cement, iron sheets, and other construction supplies delay CHC construction and impedes programme. University of Ghana http://ugspace.ug.edu.gh 18 CHAPTER THREE M E T H O D O L O G Y 3.1 STUDY DESIGN The study is a descriptive qualitative study, em ploying Focus Group D iscussions and in­ depth interviews in all the six CHPS zones in the district. These zones consist o f a cluster o f five to eight com m unities that coincide with the political electoral areas, w ith the biggest and most often the centrally placed being the location o f the com m unity health com pound. This arrangement was found convenient for conducting focus group discussions involving opinion leaders and w om en groups o f each o f the six zones. 3.2 M ETHODS OF D ATA COLLECTION The main techniques used to collect data were Focus Group D iscussions and in-depth interviews. The FGDs involved community Health Com mittees (CHC) and opinion leaders o f each o f the CHPS zones numbering nine to twelve. The opinion leaders consisted o f the chief or his representative, the Assem bly M ember for the electoral area, the Com m unity Health committee chairm an, church elder or pastor, a W ATSAN (W ater and Sanitation Committee) member, the CHO, the women organizer, and three or four com m unity elders. Views on the level and kind o f com munity support and involvem ent were solicited based on a modified Rifkin model that centred on needs assessment, leadership, organization, resource mobilization and management. Discussions with the com munity health committees were mainly based on the criteria for their selection, their roles and their relationship with the CHOs. University of Ghana http://ugspace.ug.edu.gh 19 All the FGDs were conduced in the local dialect and tape-recorded. A fter every FGD translation and transcription into English was done because the local dialects w ere used with the help o f an interpreter. The interviews consisted o f key inform ant interviews with each o f the CHOs as well as in­ depth interviews with the DDHS and the CHPS coordinator. These interview s tried to solicit inform ation regarding the extent to which the design and operation o f the programmes gave room for com m unity participation as well as their opinion on the participation o f the people. [See interview Guides in Appendix] Reports on recent studies and seminars concerning the N kwanta CHPS program m e were also reviewed. 3.3 SAMPLING PRO CED URE The opinion leaders were chosen on the basis o f their leadership and organizational roles in the communities. The com m unity health com mittees coordinate the health activities and as such their opinion was relevant. The wom en groups were selected at random from the main community in which the health com pound was situated. Each o f the six CHOs was interviewed because o f their frontline role in the day-to-day operation o f CHPS. The DDHS and the CHPS coordinator represent the DHM T who exercise adm inistrative role in the CHPS process. University of Ghana http://ugspace.ug.edu.gh 20 3.4 COM M UNITY ENTRY/ ETHICAL CLEARANCE Consent was sought from the district health authority, the chiefs and assem bly m em bers o f the areas o f the CHPS zones. Individual verbal consent was sought from the interviewees as well as the participants o f the FGDs. For the FGDs and the in-depth interview s, the participants themselves decided on the time and venue for the discussions and interviews. In conducting the FGDs special care was taken not to ask culturally inappropriate questions. The initial findings o f the study were made known to the DHM T at a forum organized for that purpose. Plans are underway to disseminate the final research report to the entire district including the com m unities in which the research was conducted. University of Ghana http://ugspace.ug.edu.gh 21 3.5 DATA PROCESSING AND ANALYSIS Data was analyzed m anually using the m odified ranking m atrix/ scale (designed by Rifkin et al (1988) based on five factors- needs assessment, leadership, organization, resource mobilization and management. Factor Scale/indicator V ery low (+1) Low (+2) Fair (+3) High (+4) Very high (+5) Needs Proiessionally Dominating Only Com m ittees/opini All assessment identified professional com m unity on leaders com munity com m ittees views. leader representing members im posed on Community representing com m unity and involved in com m unity interest com munity assess needs needs considered. views and assessm ent assess needs Leadership Leaders are Committees/o Committees Active Com mittees im posed. Do rganizations very active com m ittees well fully not represent not but some represented by represent the functioning com munities most variety o f com m unity’s m ildly active. not com munities. interest in views. Only few represented com munitie members are s. active and represent the com m unity’s views Management N o active Health staffs Communities Co-management. Self- involvem ent o f manage play active There is managemen com m unities independently role in partnership in t. in planning, w ith some managing the planning, Com munitie im plem entatio involvement CHPS implem entation, s in control n and o f committees programme m onitoring and o f planning m onitoring in some but decisions evaluation o f implementat aspects. are imposed programme. ion, by health monitoring authorities and evaluation o f the programme. organization Com mittee Committees Only Entire com m unity Entire members imposed by com munity involved in com munity University of Ghana http://ugspace.ug.edu.gh 22 imposed by health leaders or a creating the involved in planners/ professional few committees. creating health but are active. individuals Committees committees. professional were involved active but Fully active and are in creating the financially and inactive com mittees dependable. financially but are active. independent Resource No or meager No financial Periodic fund Periodic fund Considerabl mobilization resources contribution. raising raising by the e am ount o f raised by But contribute com m unity to community. resources community. in labour and support CHOs Committees raised by No support/ social or VHV, control the use o f com munity contribution o f community meetings, but funds. to support any form. No mobilization. don’t control health com m unity Provide no the activities. mobilization/o assistance to expenditure. Com mittees rganization. VHV, CHO Organize allocate the periodic money human collected. resource to help the above groups The modified Rifkin Pentagram The model involves the developm ent o f a continuum o f the five factors (needs assessment, leadership, management, organization and resource mobilization). The continuum has a wide participation at one end (+5), thus the com m unity carries out the planning, implementation, m onitoring and evaluation o f the programme with the health personnel as resource persons. A t the other end is narrow participation (+1), thus professionals make every decision without involving the people. Between these two ends are various graduations: +2, +3, +4 giving various levels o f participation. Marks w ere then put on the point that best describes the nature o f participation that is obtained. The five continua thus obtained are placed equidistant from each other and from a central point. University of Ghana http://ugspace.ug.edu.gh 23 3.6 LIM ITATIONS OF THE STUDY 1. The design o f the study is purely qualitative, employing only Focus Group Discussions and In-depth interviews. This is largely because o f the model (Rifkin model) used for the assessment. The data would have been best analyzed using Textbase Beta com puter package. But time constraints could not allow soliciting for this kind o f analysis. 2. Due to circumstances beyond the control o f the researcher Focus group discussions were not conducted in one o f the CHPS zones. 3. Levels o f com m unity participation are assumed to be the same in all the CHPS zones. Also due to the sim ilarity in socio-demographic characteristics o f the CHPS zones these possible differences are assum ed to be insignificant. The use o f Stratification m ethods could have brought out the differences. University of Ghana http://ugspace.ug.edu.gh 24 CHAPTER FOUR RESULTS 4.1 BASIC CHARACTERISTICS OF RESPONDENTS/PARTICIPANTS FG D p artic ip an ts In all fifteen focus group discussions were organized, three in each o f five CHPS zones (the FGDs in Bonakye could not come on). A total o f 134 participants were involved. The participants in each zone consisted o f a group o f the opinion leaders, the com m unity health committee, and a group o f women. The opinion leaders consisted o f the Assem blym an o f the electoral area, the ch ief or his representative, the Chairman and a m em ber o f the community health com m ittee, the CHO, the women organizer, a senior TBA, the pastor and three or four elders representing some o f the other com m unities. The w om en group consisted o f between 10 to 12 women aged 19-45 years chosen at random. Membership o f the com m unity health committee com prised of: > A representative o f each o f the communities m aking up the CHPS zone > A generally recognized and respected w om en’s leader in the zone ^ A generally recognized and respected male in the zone > A representative o f the unit com mittee/ area council 'r The Assem bly man for the area > Elder representative o f the paramount chief o f the area. University of Ghana http://ugspace.ug.edu.gh 25 D istribution o f FGD participants in the CHPS zones CHPS zone Opinion leaders W omen group Health Total com mittee Keri 10 11 8 29 Kecheibi 9 10 8 26 Bontibor 12 11 7 30 Obanda 12 12 7 31 N yam bong 10 10 8 28 Total 53 54 38 134 Interviewees Each o f the CHOs in all the six CHPS zones was interviewed. The CHOs aged between 26­ 42 are all trained com m unity health nurses who voluntarily offered to be CHOs. The medical officer in charge o f the Nkwanta hospital who is also the D istrict Director o f Health Services was also interviewed. The other interviewee was the coordinator o f the CHPS programme. 4 . 2 ASSESSM ENT RESULTS 4.21. NEEDS ASSESSM EN T This was found to be good graded +4 on the Rifkin matrix. M ost participants said all the communities were sensitized on the need to adopt CHPS. This took the form o f sub-district forums. This is the final activity in the process o f building up alliances, developing understanding and support as well as creating the basis for com munity ownership and participation for implementing the CHPS programme. These were organized to educate and inform various sections and categories o f people in the sub-district on the rclcvance o f CHPS to resolving University of Ghana http://ugspace.ug.edu.gh 26 the inadequacies in the existing com munity level health service delivery system. Two main objectives were achieved: firstly, commitment o f com m unities to the new health program expressed through suggestions o f ways in which com m unities could participate in im plem enting the programme. Secondly to obtain clear understanding o f w hat CHPS is and w hat it is not on the part o f the community members. The main activities o f the fora included: 1. Presentation by the DDHS and his team: • The district health service profile and the program o f action to address the problem o f access and quality o f service in the selected com m unities with the existing health resources. • The difference between CHPS and the previous system o f health delivery in terms o f planning, participation and placement o f nurses in the communities. • The CHPS program and the role o f com m unities in its im plem entation particularly in, Formation o f com m unity health committees, C onstruction/ acquisition o f community health com pounds Zoning o f the Subdistrict and the locating o f nurses in the zones. • Conditions that qualify communities for participation in the program; and • The health center as a referral point in the CHPS implementation. University of Ghana http://ugspace.ug.edu.gh 27 2. Open forum. Leaders and members o f the various groups represented at the forum were given the opportunity to: • Seek clarification on issues • Com ment on the new health program- express their fears and anxieties, and • Suggest ways in which the com munities could contribute to im plem enting the new program. 3. The param ount chiefs who presided over these fora were given the opportunity to express the views o f the traditional leadership on the implementation o f the program. The communities that adopted CHPS later said in some cases the com m unities organized meetings them selves and invited the health authorities to assess them for inclusion into the CHPS programme. As the A ssem blym an from Keri said: "We were praying fo r a programme like this. So when we heard o f CHPS we mobilized ourselves and contacted the health authorities in Nkwanta to fin d out how we could also have such clinics " There was also the need for advocacy and consensus building among all other health workers in the district, as explained by the DDHS: “It was also noted that it was equally important to sensitize al! health personnel about the programme and the intention to begin such programme in the districts. This sensitization process took the form o f durbars o f all health workers. The importance o f getting all health s ta ff to know about CHPS was grounded in the fact University of Ghana http://ugspace.ug.edu.gh 28 that the perceptions and reactions to its implementation can help to sustain the programme since it will not be seen to be a programme only fo r "rural health nurses " - DDHS 4.22 LEADERSHIP There is a community health com m ittee in every CHPS zone. These com m ittees are formed by chiefs and people with the DHM T and SDHT as facilitators. This is a group o f responsible personalities selected from various sections o f the com m unity and its leadership to promote com m unity ownership and participation in health care delivery. Each CHPS zone has a CHC com prising o f the following: > A representative o f each o f the com munities m aking up the CHPS zone. > A representative o f the unit com mittee/area council > The district A ssem bly m em ber from the area. > A generally recognized and respected w om en’s leader > A generally recognized and respected male in the zone. The functions and responsibilities o f the com m unity health com m ittees include the following: > Provision o f liaison between traditional leaders and health authorities y Organization o f communal activities in support o f health program m es, such as communal labor and fund raising activities in support o f service structures. > A dvocating community health and family planning activities > Settling disputes arising from the work o f the CHO, volunteers and other programme activities University of Ghana http://ugspace.ug.edu.gh 29 > Supervising the w ork o f health volunteers engaged in either disease surveillance only and or basic prim ary health care and family planning service delivery in the areas of: • Financial m anagem ent o f drugs and family planning com m odities accounts, • Managing the volunteers stock o f drugs and family planning com m odities, and • Supervising the m aintenance o f other logistics o f the volunteers such as bicycles. ^ Operates in close collaboration and consultation with the SDHT and the CHO > Advises the SDHT on com m unity reactions and involvem ent in program m e activities. > Accepts advice and supervision from the SDHT on technical issues concerning programme im plem entation such as the perform ance o f volunteers I service delivery and perform ance and attitude o f the CHOs in serving the com munity. > Serves as a protector institution to all health personnel operating in the locality and takes special responsibility for their security. In all the CHPS zones a w atchm an is provided for the CHO. In all the CHPS zones the com m unity health com m ittees play an effective role in retrieving monies owed to the health facility. "Most o f the people here are very poor, so when they come fo r treatment I cannot refuse them. I give them the treatment on credit. The committee members help a lot in making these people repay the money. The committee members stand fo r them and as soon as they get the money they come to pay through the committee CHO at Kecheibi. University of Ghana http://ugspace.ug.edu.gh 30 All the health com m ittees w ere said to be very dem ocratic in their functions: organizing meetings for people to air their views about the programme and taking decisions in consultation with the people. As the CHO for Bontibor CHPS zone expressed: “The chairman o f the health committee is very good. He visits the compound regularly and i f there is problem he informs the other members. Then they meet and also invite me and the a ssem b ly m a n C H O at Bontibor. The CHPS coordinator w as also seen to be part o f the leadership and w orked very closely with them. "Anytime he visits this place (Keri) he makes sure me or any other member o f the committee is informed beforehand. There is no decision made concerning the programme in this zone without consulting the chairman or the Assemblyman. He accepts whatever we tell him to be the problems here and tries to help us solve them Health Committee chairman at Keri. The CHOs were also found to be generally w orking very hard to the satisfaction o f the people. "The nurse here is very hard working. She has never turned away any patient no matter the time o f the day he or she comes to the clinic community elder at Obanda. University of Ghana http://ugspace.ug.edu.gh 31 "The nurse here is hardworking and devoted but because she is the only one she often gets very tired. But the volunteer is so good that they can work together throughout the day especially on market days "-opinion leader at Bontibor. Hence the health com m ittees generally provide the com munity leadership in the program, are active and have representation from most communities. Leadership was also therefore found to be high (+4). 5.23 ORGANIZATION The DHM T was generally seen to be the main organizers o f the programme. In all the FGDs the DDHS was m entioned as the main brain behind the CHPS programme. "Dr. Awoonor and his team have played leading roles in bringing to us this CHPS. When we wrote letters to him fo r this programme he sent his assistants to assess us. Then after that he gave us the go ahead. When he saw our enthusiasm and participation he arranged fo r the NGOs to assist us ch ief o f Bontibor.. The officer responsible for the day-to-day supervision and monitoring o f the program m e is the CHPS coordinator. He pays regular visits to the CHPS zones. During these visits he finds out the problem s o f the CHOs and the concerns o f the health com mittees. He also supplies materials and item s and inspects the health com pounds for maintenance. These visits are very im portant not only to find out problem s but also to reassure the nurse that we are interested in her welfare. University of Ghana http://ugspace.ug.edu.gh 32 The activities o f the H ealth committees have helped greatly in surveillance system in Nkwanta district. In the Nyanbong CHPS zone the Health com m ittee has been able to sensitize the entire com m unity to feel compelled to report any cases o f sickness, birth death or any unusual event. A ny o f these events is reported to any o f the com m ittee m em bers who in turn report to the CHO. The CHO then makes the necessary docum entation and forwards to the surveillance officer in Nkwanta. The surveillance officer in N kw anta makes follow-ups o f the reported cases and then makes weekly feedback reports to all the CHOPS zones. Included in these feedback reports are the perform ances o f all the CHPS zones. In this way all other CHOs know the perform ance o f the others. 4.24 M ANAGEM ENT This is placed on scale +4. Management o f the program m e is generally a partnership between the DH M T and the communities in the areas o f planning, implementation and evaluation. This co-m anagem ent arrangement is m ade possible by the wide room o f flexibility the DDHS gives to all the agents involved in carrying out the programme activities. Both the CHO and the coordinator o f the program m e are given their ow n impress to manage. This arrangem ent has made the CHOs feel m ore autonom ous in their new professional role, and this conveys a sense o f pride and status that was lacking in their former roles. University of Ghana http://ugspace.ug.edu.gh 33 Here I am boss o f m y own. I am the m anager and the accountant as well. I face a lot o f challenges alone and when I overcome them I feel very happy and satisfied. CHO at Bonakye. 4.25 RESOURCE M OBILIZATION This indicator was given a score o f +4 (i.e. high) on the Rifkin scale. The main contribution o f the communities in the CHPS program m e is in building up the community health com pounds. The health com pound is a housing facility where the CHO lives and dispenses health care. It is a two-bedroom facility with a living room and a separate room for providing health care to patients. There is also a pavilion in which maternal and child health M CH services are given. In all the com munities the people provided the land, labour, sand and gravel, w ood for the construction o f the health com pounds. The main com m unity m obilizers in all these activities are the health com mittees. However the basic equipm ent used have been provided for by the DHM T with the help from DANIDA and W orld Vision, two m ain N G Os in the area. The people are limited in the area o f financial contribution, as this elder from Nyanbong said: "We would have wished we could contribute financially to support our nurse but here the ordinary man cannot even get one thousand cedis. However we arc ready to do anything within our strength to keep this CHPS going ", University of Ghana http://ugspace.ug.edu.gh 34 In all the zones the health com m ittees organize people to weed around the com pounds. In five o f the zones the com m unity members have helped the CHO to put up farms as stated by the health com m ittee chairman in Obanda. “We know she is our doctor here day and night, so she cannot get time to make a farm to supplement her salary. We have made a cassava and maize farm fo r her and the community is in charge o f maintaining it till harvest lime " The CHOs in all the CHPS zones also enjoy gifts from the com m unity members. During the harvest season most people bring to her some yam, cassava and com. "We give her these foodstuffs so that she can continue to stay with us and help our women and children when they are sick" - A ssem blym an o f Kecheibi CHPS At Obanda Keri and B ontibor some community members occasionally com e to help the nurse to cook and to wash her clothing. All the zones have watchmen who are employed and paid by the health com mittees. All the CHOs have one or two volunteers who have been accepted as volunteers on he basis o f their leadership and membership o f a social group in the community, proven record o f active participation in communal work and proven record o f stable character, volunteerism, trust worthiness and honesty. W hen the com m unities choose the volunteers they are given training by the DHM T and presented to the people at a durbar o f chiefs and people organized for such purpose. Having been selected from the various communities they serve as a link between the community leadership and the Health com m unity and the University of Ghana http://ugspace.ug.edu.gh 35 SDHT in the dissem ination o f inform ation on programme im plementation. They also serve as links between the CHOs and individual families. "The volunteers are veiy good. Whenever madam is not there they take up most o f her duties. They can treat minor cuts, can dispense drugs, give advice to patients. They can even help when a child who is convulsing. In fa c t they are veiy good and devoted to their work" - elder from Nyam bong CHPS zone. In general the health volunteers help to: ■ Provide curative and preventive services for malaria and diarrhea ■ Provide family planning services and counseling ■ Deliver health education talks and ■ Take part in disease surveillance activities. University of Ghana http://ugspace.ug.edu.gh 36 CHAPTER FIVE C O N C L U SIO N AND R E C O M M E N D A IO N S 5.1 CONCLUSION Com munity participation in the CHPS programme in N kw anta district was generally found to be high. The operation o f the programme has been a functional and interactive process between the health care practitioners and com munity members. There is high enthusiasm and spirit o f self-help. The people are involved in a partnership w ith professionals in planning and implem entation, monitoring and evaluation o f program m e activities. The communities are involved in decision making process and contribute imm ense resources. Their in-kind contributions have been the main m otivation for the CHOs to continue to stay and w ork with them. The people are generally satisfied working with the programme managers and som e N G Os as their main source o f cash flows and technical support while feeling they own the programme and a sense o f duty to contribute to i t’s operation and sustainability. 5.2 RECOM M ENDATIONS It is encouraging to find that com munity participation in the CHPS process in Nkwanta district is high. This gives an indication o f sustainability o f the program m e since such com munity-based programmes depend very much on the com m unities’ involvem ent and participation. However this communal spirit o f involvement and sense o f ownership for the programme did not come automatically and should not be taken for granted. In adopting CHPS the programme implemcnters had to concretely conceptualize its operations by University of Ghana http://ugspace.ug.edu.gh 37 doing a thorough situational analysis and applying a great deal o f initiative and innovation.. Tremendous am ount o f w ork was done with huge cost in tim e and resources to first secure the cooperation and authorization o f the people themselves at the com m unity level before implementing the programme. Every com m unity has the potential o f active participation in any program m e meant for their welfare. But the level o f actual participation in a program m e will depend on how community m embers have been made to perceive the program m e through effective community sensitization, m obilization and education. The D H M T and the SDHT o f Nkwanta did a great job in this regard. Therefore while making the following recommendations for the enhancem ent o f the CHPS process, the DHM T and the SDM T is strongly commended for their successful pioneering role in the CHPS process in Ghana. 5.21 THE CHOs Inter personal relationship Community participation in CHPS is strongly associated with the attitude o f the CHOs who are the front-line service providers. A good interpersonal relationship between the CHOs and community members will go a long way to enhance continued participation and hence improvement in health indicators. It is therefore recommended that the DHM T should undertake periodic surveys on the com m unity’s views on the attitude o f the CHOs. This stems from the fact that the DDHS has had occasion to receive com plaints from some University of Ghana http://ugspace.ug.edu.gh 38 CHOs about the uncooperative attitude o f some community members. But in order to have a fair and well-inform ed idea about issues it is equally important to hear w hat the people also say about the attitude o f the CHOs. Motivational factors Out o f the 17 CHNs in the district only six o f them are involved in CHPS and they provide primary health care to 23.2 percent o f the people in the district, who otherw ise would not have access to any health facility. M ore so these CHOs are stationed in very deprived areas where they lack basic social am enities and are separated from their spouses. Even though the communities try to do w hatever in their capacity to motivate them workable motivational packages should be explored to further motivate them to continue to give up their best in those difficult and trying conditions. Among the incentives the CHOs ask for include T.V sets, loans for housing schemes, sponsorship o f their children’s education and continuous education in the form o f refresher courses for them. The DHM T could create buffer o f CHOs so that after every three years o f w ork at a particular zone she could go for further course in m idwifery or other course to upgrade her knowledge and skills. Reorienting all CHNs The efficient and effective use o f Com m unity Health N urses as CHOs in the CHPS programme dem onstrates that working as CHOs in the CHPS process is indeed the rightful job for all CHNs. As such, the curriculum for the training o f CHNs should be enriched to include rural sociology, managerial and leadership courses, and interpersonal relationship. University of Ghana http://ugspace.ug.edu.gh 39 These courses will enhance them w ith the requisite knowledge, skills and attitude to work in rural deprived areas in the country. 5.22 THE HEALTH VOLUNTEERS It is noted that the com m unity health volunteers play a significant role in the CHPS programme. To sustain their morale, enthusiasm and spirit o f volunteerism the DHM T should continue as they are doing to motivate them by giving them bicycles, inviting them for workshops in N kw anta and giving them in-service training to upgrade their skills and competencies. Regular m eetings with them to discuss their problem s will help boost their morale. 5.23 TUTUKPENE HEALTH CENTER The Tutukpene health centre has been closed down for som e time now. Some o f the reasons for the closure o f this huge well-equipped health center includes lack o f a proper need assessment and low attendance o f community members. An in-depth research should be conducted to unearth the underlying causes o f these problem s. Turning this center into a CHPS facility and follow ing sim ilar steps for the establishm ent o f CHPS could make is very useful to the people. Responses I got from my interaction w ith the A ssem blym an for Tutukpene intimates this is feasible. University of Ghana http://ugspace.ug.edu.gh 40 5.24 COSTING AND EVALUATION OF COM M UNITY CONTRIBUTIONS The hallmark o f com m unity participation in the CHPS is the in-kind contributions o f the people in terms o f providing labour, wood, foodstuffs and security for the CHOs. It is important to cost all these contributions so that the people can tell quantitatively their level o f support for the program m e. This will also make it possible for all the com m unities to know how much each is contributing relative to the other. The quantified am ounts o f the contributions o f all the com m unities should be made known to them at durbars and those with more contributions com mended. 5.25 INTERSECTORAL COLLABORATION DANIDA and W orld V ision International have made significant contributions in the CHPS process by helping to build Com m unity Health Compounds and donating m otorbikes for the CHOs. W hile com m ending these organizations for those contributions, it is suggested that they intensify their educational programmes in those areas to help em power the people. Not too much enthusiasm is shown by the District Assembly. Their effective involvem ent in the CHPS process will go a long way to sustain the programme. W orkshops should be organized to educate them on the CHPS process 5.26 ADOPTING CHPS IN TH E DISTRICTS An important lesson that should be learnt from the CHPS process in N kw anta is “'starting small” Once a DHM T is convinced that CHPS should be started, it should start on a pilot basis. On the basis o f success o f the pilot programme the programme can then be scaled up. University of Ghana http://ugspace.ug.edu.gh 41 The Nkwanta team has dem onstrated that w ithout funding from external sources, CHPS can be implemented all the funding from the NGOS were solicited only after dem onstrating that local resources could be m obilized to start a health programme. To be able to do this requires building a good team driven by a leadership with vision, initiative and innovation. This team should build mutual trust w ith the com munities. Giving promises that can and m ust be fulfilled is key to building this mutual trust. 5.27 SURVEILLANCE The Nkwanta CHPS program m e has an in-built surveillance system that is very efficient and effective. In N yam bong for instance hardly any event (birth, death, outbreak o f disease or unusual health related event) occurs without a report being made to the health com m ittee and to the CHO. As the assemblyman for the area explained it is a rule in the area to report all such cases. This com m unity initiative can be encouraged in all districts that are trying to implement CHPS so as to m ake the surveillance m ore sensitive. University of Ghana http://ugspace.ug.edu.gh 42 REFERENCES 1. Address by Dr. H. Mahler, Director General o f W HO, to the International Conference on PHC, Alma-Ata, 6 September 1978, in F rom A lm a-A ta to the y ea r 2000: R eflections at the M idpoint. 2. Atim , C et al: T ra in in g of T ra in e rs m anual F o r M u tu a l H ealth O rg an iza tio n s : ABT Associates Inc, September 2000. 3. Berm ejo, A and Bekui, A.: ‘Community Participation in D isease Control', Social Science M edicine, Vol. 36 no 9. 4. Ong, B. N: R ap id A ppra isa l and H ealth Policy, Chapm an and Hall, London, 1996. 5. Laleman, G .and S. Annys: ‘Understanding Community Participation: a Health Programme in the Philippines'. H ealth Policy an d P lann ing , A jo u rn a l on H ealth in D evelopm ent, vol. 8, no 3, Septem ber 1993. University of Ghana http://ugspace.ug.edu.gh 43 6. M edium T erm H ealth S tra tegy T ow ards V ision 2020, M OH, Accra, 1999. 7. Navrongo Health Research Centre (NHRC), MOH: T h e N avrongo C om m unity H ealth and fam ily P lann ing P ro ject: Lessons L earned , 1994-1998. 8. N kw an ta D isric t H ealth Services A nnual R epo rt, 2000. 9. Rifkin et al: ’Prim ary Health Care: on measuring P artic ipa tion’, Social Science a n d M edicine, 26 (9) 10. Schmidt, D .H. and S. B. Rifkin: ‘M easuring Participation: Its Use as a M anagem ent Tool fo r D istrict Health Planners based on a Case Study in Tanzania', In te rn a tio n a l Jo u rn a l o f H ealth P lann ing an d m anagem ent, V ol.11, 1996. 11. Twumasi, P. A: Social Science in R u ra l C om m unities, Ghana Universities Press, Accra. University of Ghana http://ugspace.ug.edu.gh 44 APPENDIX (A ) IN-DEPTH INTERVIEW GUIDE FOR THE DDHS 1. W hat factors influenced your decision to adopt CHPS 2. W hat steps were taking in implementing the programme? 3. W hat have been the challenges/ problems 4. W hat steps are taken to sustain CHPS 5. W hat are your im pressions about the level o f com munity enthusiasm and participation in the program m e (B) IN D EPTH INTERVIEW GUIDE FOR THE CHOS 1. W hy/ how did you becom e a CHO? 2. W hat activities are carried out in this CHPS zone? 3. Which com m unities are w ithin your coverage area? 4. W hat is the population o f your coverage area? 5. W hat facilities are available in this CHC? 6. How do the com m unities contribute to the programme? 7. What are the m ajor problem s / challenges that you face as a CHO? University of Ghana http://ugspace.ug.edu.gh 45 © FOCUS GROUP DISCUSSION GUIDE FOR OPINION LEADERS IN TH E CHPS ZONES NEEDS ASSESSM ENT 1. How were the initial needs o f the com munity identified? 2. Who were involved in the process o f the needs identification? 3. Are there new needs? 4. Why should the program m e continue? LEADERSHIP 1. Who make up the leadership o f the programme? 2. Is the leadership dem ocratic or autocratic? 3. Is the leadership capable? 4. Is there the need to change the leadership? OGANIZATION 1. Who are involved in carrying out the programme? 2. Is there effective collaboration between these groups? 3. Are com munity members involved in carrying out th program m e activities? University of Ghana http://ugspace.ug.edu.gh 46 4. Will the com m unity be able to continue with the programme if donors w ithdraw her assistance? RESOURCE M O BILZATIO N 1. Who contributes to the programme in terms o f finances and human resource? 2. W hat has the com m unity contributed and what percentage o f this is total programme cost? 3. Whose interest is served by the allocation o f resources? 4. How are resources m obilized? MANAGEMENT (DECISION MAKING') 1. How are decisions made? i.e. Are ideas discussed then decisions made through collaboration, or are decisions imposed on the programme? 2. Would you like to see this process changed, if so how? 3. Rate the influence the leaders and the individuals have in determ ining activities and the actions o f the programme. Who do you think has the most influence? 4. Has this level o f influence, which the different groups (i.e. leadership, individuals and com munity exert), changed since the program m e began? If so how, and in which direction?