blthr C.l G3S2707 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh COMMUNITY HEALTH WORKERS IN THE PRIMARY HEALTH CARE (PHC) PROGRAMME IN RURAL GHANA. A STUDY AT NKORANZA BY STEPHEN OPOKU-TUFFUOR DEPARTMENT OF SOCIOLOGY, UNIVERSITY OF GHANA, LEGON A THESIS BEING SUBMITTED TO UNIVERSITY OF GHANA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS OF THE DEGREE OF MASTER OF ARTS IN SOCIOLOGY. SUPERVISORS, DR. ELLEN BOTEI-DOKU T'-JU, f l i g DATE PROF. MAX ASSIMENG I n i l k , . Q - SIGNATURE ->». •»»>.— In .............................. \ SIGNATURE DATE University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh C O M M U N I T Y H E A L T H U I O R K E R S I N T H E P R I M A R Y H E A L T H C A R E (P H C ) P R O G R A M M E IN R U R A L G H A N A . A S T U D Y A T N K O R A N Z A B Y S T E P H E N O P O K U - T U F F U O R D E P A R T M E N T O F S O C I O L O G Y , U N I V E R S I T Y O F G H A N A , L E G O N . A T H E S I S B E I N G S U B M I T T E D T O U N I V E R S I T Y O F G H A N A IN P A R T I A L F U L F I L M E N T O F T H E R E Q U I R E M E N T S F O R T H E D E G R E E O F M A S T E R O F A R T S I N S O C I O L O G Y . S U P E R V I S O R S , D R . E L L E N B O T E I - D O K U W ? * . v i j___ *'>5 S I G N A T U R E D A T E P R O F - M A X A S S I M E N G S I G N A T U R E D A T E University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh D E D I C A T I O N THIS PIECE IS DEDICATED TO THE RURAL MAJORITY WHO PROVIDE AMENITIES THEY DO NOT ENJOY. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh D E C L A R A T I O N THIS THESIS IS THE RESULT OF MY ORIGINAL WORK AND INDEPENDENT RESEARCH UNDERTAKEN WHILE I WAS A STUDENT AT THE DEPARTMENT OF SOCIOLOGY, UNIVERSITY OF GHANA, LEGON FROM OCTOBER, 1988 - AUGUST, 1990. ALL QUOTED SOURCES HAVE BEEN ACKNOWLEDGED. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh A C K N O W L E D G E M E N T This thesis is being presented to the University o f Ghana in partial fulfillment o f the requirements for the M.A. Degree in Sociology. Academic success needs the contributions o f many individuals - those who have to plan to impart knowledge, those who have to provide the financial and material support, and those who provide the spiritual and the moral support. I am thus indebted to those who have brought me so far. I would like to take this opportunity to thank all my teachers. This work would not have been successful without the guidance o f my team o f supervisors - Prof. P. A. Twumasi, Prof. Max Assimeng and Dr. Ellen Botei-Doku who chaired the team. I cannot fully express my indebtedness to them. I very m uch appreciate their valuable criticisms and suggestions which have shaped the thesis in the way it is now. W ithout their backing and encouragement this thesis might not have been written. I thank Mr. Tesfy Teklu, a lecturer at the Regional Institute for Population studies and Mr. K. A. Senah a lecturer at the Department o f Sociology for their interest in me and in this work. Their suggestions to this work from the beginning to the end put me on the right track. I am a debtor to my senior brothers who have all these long years continued to support me in school. To them I say “AYIKOO”. Mr. Lanquaye Lamptey o f Ghana Water and Sewerage Corporation and Mr., James Boateng o f Pioneer Tobacco Company need my special thanks. The contributions they made towards this work were immense. If writing o f the script was difficult and needed a lot o f brain storming to put ideas together, then equally a difficult task is the typing o f whatever is hand written. This is University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh what Ms. Sophia Pappoe o f Ghana Water Sewerage Corporation, Head Office, Accra did. The competence with which she typed this work and the long hours she sat down without demanding any reward is sometimes difficult to think about. Sophia, I say thank you. I will remember your scarifies any time I think o f my M. A. Degree. I also thank my informants who had to sacrifice their time and energy. To those who provided accommodation, food and water, I render my special thanks. I cannot forget the contributions o f Dr. Bossman o f St. Theresah’s Hospital, Nkoranza, (District Medical Officer o f Health) and Mr. Kumi, (PHC District Co-ordinator). I must say, however, that I am solely responsible for the shortcomings which may be found in the work. S. OPOKU - TUFFUOR University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh A B S T R A C T The search for a m or^ equitable health care delivery system to cover the majority o f the people, more especially the Vulnerable groups (women and children) has led many developing countries including Ghana to adopt the Primary Health Care (PHC) programme. Primary Health Care as envisaged, is to make health care available, accessible and affordable to the underprivileged an also to enable the people and the system is to serve to participate in its planning and implementation. Community Health Workers (CHWs) have been identified as the corner-stone o f such a programme. Ghana has thus found it appropriate to use such community-trained health care providers. Using a sample o f 32 CHWS, some leaders o f the communities o f the 32 CHWs and some health personnel in the h Nkoranza area in the Brong-Ahafo Region o f Ghana, an attempt has been made to examine factors affecting the performance o f CHWs in the implementation o f the CHW programme in rural Ghana (chapter 1). The thesis as demonstrated in cCapter Two, has shown that the programme took o ff w ith the participation o f the communities concerned, the government o f Ghana (through the Ministry o f Health) and the various non-governmental organisations UNICEF, WHO, World Vision International and Catholic Secretariat. The research has however revealed that the institutionalization o f the programme has not recorded much success (as shown in chapters 4,5 and 6). The state o f affairs in the organization o f community clinics is attributed to among other things, the lack o f community education on the programme and improper p l a n n i n g and development o f the necessary support systems. These factors which are interrelated and interconnected have damped the enthusiasm o f the community members and most o f the trained CHWs, The end result is that, about 80% o f the CHWs have abandoned the programme. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh While some measures such as the organization o f fund raising activities and the training o f community leaders in management skills could be adopted locally to deal with the problems o f remuneration, supervision and drug supplies, more comprehensive measures will be needed at the national level to reshape the programme to meet the needs o f the rural majority (Chapter 7). University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 1,1ST OF TABLES TABLE 1.1 Community Clinic Attendance Attrition Rates 5 1.2 Distribution o f Community Clinics by status 18 as o f the Survey Data 2.1 Recurrent Health Expenditure by sub-sector 57 (000) 1977/78 - 1988 3.1 School Enrollment in the Nkoranza District 3 0 4.1 Duration o f Training Among CHWs in Nkoranza 66 4.2 Training in health Care Among CHWs in Nkoranza 68 4.3 CHWs by M ode o f Selection 72 4.4 Selection criteria o f CHWs by Communities in Nkoranza 76 4.5 Provision o f place o f work for CHWs by Nature o f Tenancy: 78 Nkoranza 4.6 CHWs by amount o f Allowance given during 80 training/week 4.7 CHWs by Amount o f Allowance to be paid by 82 Communities as remuneration 5.1 Opinion o f CHWs on the Availability o f 89 Training Manuals 5.2 CHWs Preference o f Supervisory visits from 90 Health Authorities University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh LIST OF DIAGRAMES Factors Affecting CHWs in the Nkoranza District as Revealed by the Research University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENT CHAPTER ONE PAGE INTRODUCTION 1.2 Statement o f the Problem 1 1.2 Objectives o f the Study 6 1.3 Literature Review 6 1.4 Theoretical Focus 9 1.5 Field M ethodology 18 CHAPTER TWO THE HISTORICAL DEVELOPMENT OF THE PHC AND CHW CONCEPT IN GHANA 25 2.1 Ghana’s Conventional Medical Model 25 2.2 Disillution with the Medical Care Model 31 2.3 Changing Ideas about Poverty, Health and Development 33 2.4 The Development o f the PHC Programme in Ghana: The Kintampo Project 40 CHAPTER THREE SOCIAL STRUCTURE OF THE NKORANZA DTSTRTCT 53 3.1 Socio-Economic and Cultural Organization o f the Nkoranza District 53 3.2 Social Infrastructure 56 CHAPTER FOUR COMMUNITY PARTICIPATION IN THE IMPLEMENTATION OF THE CHW PROGRAMME IN THE NKORANZA DTSTRTCT 62 4.1 Introduction 62 4.2 Characteristics o f the CHW Training Programme 65 4.3 Community Assistance in the CHW Programme 70 4.3.1 Community Involvement in the Selection and Training o f CHWs 71 4.3.2 Supervision o f CHWs by Community 76 4.4 Community Material Assistance to the CHWs 77 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 4.5 Community Financial Assistance to CHWs 79 4.5.1 Community Financial Assistant for Drug Supply 82 4.5.2 Community In Kind Assistance to CHWs 85 CHAPTER 5 MOH PARTICIPATION IN THF, IMPLEMENTATION OF THE CHW PROGRAM M E TN THF, NKORANZA DISTRICT 88 5.1 MOH Technical Assistance 88 5.1.1 Provision o f Training Manual 88 5.1.2 Provision o f Supervisory Visits 89 5.1.3 Provision o f Refresher courses 92 5.1.4 Provision o f Referral Points 92 5.2 MOH Material Assistance in the Programme 95 5.3 MOH Financial Assistance to the CHWs 96 CHAPTER SIX CHW ’S PERCEPTIONS. EXPECTATIONS AND EXPERIENCES AND HOW THESE ARE AFFECTING THEIR FUNCTIONS IN THE NKORANZA AREA 97 6.1 Perceptions o f CHWs 97 6.2 Expectations 98 6.3 Experiences 99 6.4 M anagement o f Clinic Funds 101 CHAPTER SEVEN 7.1 Conclusions and Recommendations 7.2 Conclusions 7.3 Recommendations 103 106 110 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 1 C H A P T E R O N E INTRODUCTION 1.1 STATEMENT OF THE PROBLEM: This thesis attempts to look at the official health sector and community related factors which affect the work o f Community Health Workers who are the frontline workers, o f the PHC delivery system. It has been realised o f late that it is near impossible in many developing countries to reach the rural population with clinic-based health services. Capital budgets to construct facilities and recurrent budgets to pay for staff or supplies are limited. These have been aggravated by falling prices o f commodities, increasing population increasing security operations following frequent coup d'etats. Most o f these countries have inadequate transportation systems, and health personnel are often reluctant to work in remote areas. In others, health services do not reach most people because they are too distant and inaccessible for technical, linguistic or cultural reasons. Since the Alma-Ata Declaration in 1978, a keen awareness has developed on the shortcomings in the delivery o f health services and the need for policies and programmes which reflect peoples requirements to an increased degree. Furthermore, it has become clear that many health interventions have to be performed by people based at home rather than in institutions. The WHO initiated the movement towards the development o f a Primary Health Care (PHC) programme in the rural areas in 1975. A study carried out by Djukanovic and Mach (1975) as a joint project for WHO and the United Nations Children's Fund (UNICEF) underlined the lack o f adequate health services in the villages. They advocated the appointment of PHC workers with broad backgrounds, and with a commitment to community participation. Participation was obviously necessary if health education was to be relevant in local terms and effective in changing behaviour; but there University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 2 was also the growing belief that people should have more say in decisions which would affect them and their families so intimately (Newell, 1975; Morley et al 1983). In 1977, the WHO published its Working Guide for Primary Health Workers (PHWs) (WHO, 1977) giving detailed advice, in both words and pictures, about how to deal with local health problems. The topics ranged from childbirth and family welfare to village hygiene, and from the treatment o f accidents or internal growths on ths one hand to mental disorder on the other. This explains why many developing countries have recently been experimenting with the delivery o f primary health care at the community level by promoting "self-help" programmes among villagers facilitated by village level health workers. A precedent had been set by the barefoot doctors in China, the promotoras de salud in Guatemala, and the village health workers in Niger. M ost countries have thus expressed a commitment to the CHW programme, signing Charters, making declarations and publishing policy statements, and many have set national goals and prepared programmes for the organization and management o f their health systems on this basis. About three-quarters (3/4) o f developing countries thus have national plans indicating how their health infrastructure may be extended and re-oriented to achieve the goals o f PHC. Since her adoption o f the PHC concept in 1976, Ghana has been incorporating new approaches and activities into her national health programme. The emphasis has been on the training o f health workers in broader professional field instead o f using health workers trained intensively for a limited range o f tasks. In Ghana, Community Health Workers (CHWs) have been recruited as part o f an effort by the Danfa Comprehensive Rural Health and Family Planning Project to augment village-based Services. The reason being that community members trained in health University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 3 education can educate their people better. Village volunteers have also assisted in the Danfa project's Mass Immunization, M alaria Chemoprophylaxis, and self-help sanitation programmes. In other village-based activities Traditional Birth Attendants (TBAs) have been trained to deliver maternal care, and health education volunteers have been taught to monitor the growth o f children and to provide education on nutrition. There seems to be two main reasons for employing such health workers in Ghana. 1. The failure o f health centre-based services to meet the health needs o f the people it was intended to serve and at a cost they could afford. 2. The realisation that simple medical and nursing care and the use o f medicaments alone can have little effect on the environmental, social and cultural factors that cause disease and disability. Thus the assumptions underlying PHC and the use o f CHWs in Ghana are that CHWs would more successfully disseminate health information, and also that Community participation is integral to the institutionalization o f CHWs programme at the Community level. In short, Ghana is promoting CHW programme as a more equitable alternative to an earlier medical model that is primarily curative, urban and hospital-based, inadequate for its exclusion o f even minimal services to the majority o f the people and which has been seen as too expensive to extend to all areas. The principles which formed the basis o f the CHW approach were equity, intersectoral collaboration, community involvement, emphasis on prevention, and appropriate technology. CHW programmes were in many ways seen as encompassing all these principles: equity by extending services to neglected populations, intersectoral collaboration through working with community workers o f other sectors and indigenous practitioners, and including tasks traditionally seen as beyond the health sector (such as University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 4 education on Water management and Sanitation) Community involvement through their close links with communities. It is for the realisation o f this broad objective that the Ghana Government under Acheampong initiated the Brong-Ahafo Rural Integrated Development Programme (BARIDEP) (referred to in this work as "the Kintampo Project") for the training o f CHWs. It can therefore be said that the training o f CHWs at Kintampo (Health Centre) and the subsequent establishment o f Community Clinics (CCs) in rural Ghana in general (and Nkoranza District in particular) are part o f government planned actions. They are designed to intervene in the health care delivery systems, by bringing health services to people in places that the official health services cannot reach. CHWs are thus seen in this context as a part o f an instrument o f development and change. Although Ghana's PHC programme in general and the Kintampo project in particular have been in operation for over 15 years impressions one gathers through regular visits to the villages within the Nkoranza District (i.e. the pilot CHW project area) are that only few o f the many trained CHWs in the area are still working. This notwithstanding, various successive governments and other non-governmental organisations working in the area o f health and community development continue to place emphasis on the use o f CHWs as the key to Ghana’s rural health problems. According to the annual report (1989 report) o f the St. Theresah's Hospital, Nkoranza, there were only 12 "active community clinics in the district even though more than 60 people from 60 different communities had been trained in the area. The truth o f the matter is that, while some communities could not establish clinics for their trainees, clinics established by others could not be sustained due to reasons to be examined later This situation is not limited to the district; the country as a whole has caused the health authorities to suspend the training o f CHWs, believing that "the whole concept o f CHWs needs careful evaluation first" (Health Services Report o f Nkoranza District; University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 5 1989). Adjei Sam et al (1989) have also showed that in nine districts they visited during their study on the viability o f Community Clinic Attendants in Ghana, the average attrition rate per district was 74.5%. The exact rate for the various districts is given in the table below: Table 1.1 Community Clinic Attendant Attrition Rates for Various Districts DISTRICT NO.OF CCAS TRAINED ATTRITION ATTRITION RATE Afutu-Awutu Senya 59 41 70% Suhum-Kraboa-Coaltar 69 49 70% West Dagomba 167 NA NA Ashante-Akim 46 36 78 Kintampo Only three Community Clinics were private basis. operating but on Bongo 16 8 50% Wassa West 48 38 79% Dangbe West NA NA NA Volta NA NA NA SOURCE: Summary Report on the Activities o f CCAS p.3 Although data could not be found by Adjei and his team for the Dangbe W est District, it was later found out (during a research into the Implementation o f the Bamako Initiative Programme 1990) that only 2 o f the 11 trained CCAS in the district were working. Despite this stand the interest o f the Communities to have clinics is still high, for whilst most communities have recently started reviving their defunct clinics, new ones are been established in places where some could not be established initially. The time is therefore ripe for this type o f sociological study in the pilot programme area, to find out what factors are affecting CHWs in rural areas. This is expected to serve as a baseline data material for PHC Planners in Ghana. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 6 1.2 OBJECTIVES OF THE STUDY Main Objective: The main objective o f the research is to identify official (health sector) and community-based factors that affect the functioning o f Community Health Workers in rural Ghana, with particular reference to the Nkoranza area in the Brong-Ahafo Region. Specific Objectives: Specifically, the research will look at: 1. The type and level o f MOH participation in the institutionalization o f ■ CHW programme and their role in the operations o f CHWs in the study area. 2. The type and level o f community articipation in the CHW programme and the effect o f these on the successes or otherwise o f CHW s in the study area. 3. CHW ’s own perceptions and experiences and how these inputs affect their work in the study area. 1.3 LITERATURE REVIEW Cohen and U phoff (1977), Coombs (1980) and Jancloes et al view community participation as the key to successful CHW programme. They consider all other factors that influence the work o f CHWs as complementary to community participation. Jancloes et al, suggested that when people are given the opportunity to manage their own affairs and to be involved in decision making they can become very efficient and will contribute many o f the material and human resources needed to organise health facilities. This is the assumption worked into the PHC and the CHII programmes. Even though Jancloes et al (op.cit) see the importance o f community participation in carrying out development programmes, what they did not address themselves to is the issue o f who is to do what and how. Thus whether community participation in decision making is to be carried out University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 7 by the whole community or through their representatives who are delegated specifically to do this is not clear from the argument. Although Schumacher (1973); WHO/UNICEF (1978); M olina et al 1980 and Ballondi et al (1980), support the community participation idea, they argue that community participation in development programmes can only be effective where the people are consscientised. Thus, any programme that aims at seeking the support o f the people should first educate the people to understand the programme and the specific role they are expected to play. Although education o f the people is emphasised here as a tool to get a people to be involved in a development programme, the question o f whether the particular project or programme is the felt need o f the people is overlooked. Bose (1983) on the other hand sees a relationship between people’s perceptions about the services rendered by CHWs and the extent to which they participate in such CHW programmes. To him, rural masses tend to perceive their health problems in terms o f getting access to medicines, doctors and hospitals. They therefore tend to judge CHWs negatively because o f their limited competence in curative health care. The end result o f this situation among the people CHWs serve is a feeling o f helplessness and frustration and this affects community participation in CHW programmes. Two things are not clear from Bose's argument. Firstly, whether the views expressed about CHWs represent the views ot the educated elites or that o f the common rural masses is not distinguished. Secondly, what impact education (conscientisation) o f the people about the programme and the functions o f its structures can make on their participation is not made clear. Segall and W illiams (1980), Muller (1980), de Kadt (1983), and Twumasi and Freund (1988) see a direct relationship between the implementation o f development programmes and the political system or the social structure o f the given society. An idea derived from these writers is that people remain socially and culturally attached to such structures and their traditional patterns o f leadership and/or co-operation. To M uller (1980), this can be utilized to mobilize community members in decision making about University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 8 actions to improve their health and general conditions. On social structure and community participation, the writers are o f the opinion that where material resources are more equally distributed, there appears to be a better basis for community activities. Nevertheless, even in such circumstances it may be difficult to involve community members in health promotion if there are ethnic or clan divisions. The Institute o f Development Studies (IDS) (U.K.) research group (1978) considers technical support as another factor that affects PHC programmes at the community level. First, the IDS considers community participation in rural areas as an enthusiastic contribution towards the promotion o f health needs. However, the report maintains that the villagers are extremely conscious o f their lack o f technical knowledge as far as health matters are concerned. They are therefore confident that advice from outside will be useful. In the opinion o f the IDS report therefore, any approach directed towards the institutionalisation o f PHC programmes at the community level without the active involvement o f health personnel and social workers will fail. It must however be mentioned that at what point and in what form the health personnel are to be involved in the programme is not shown. Although this argument is supported by Morley et al (1984) they add that part o f this technological package should include knowledge o f the health problems o f the area. Appropriate technology should also extend to training and management strategies, and to monitoring and evaluation using precise indicators by which a community can gauge its progress in solving health problems. Morley et al have further argued that these technical factors alone will not guarantee a successful PHC programme in the rural areas, but they are essential and tend to be overlooked by those for whom social goals are paramount in PHC. Navarro (1975), and Lamptey et al (1980) have explored the role o f health personnel and social workers in the implementation ot PHC programmes. Their study has established the importance o f involving health personnel and social workers actively in University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 9 government projects and community initiated ones. However, they are o f the view that there is the need to find out the extent to which the people should be involved. To them, the current bureaucratic and dominant profession such as the bio-medical practitioners would have to yield a great deal o f their control if the PHC system should work. Securing financial support for PHC programmes has been identified as a major bottleneck While Rifkin (1980) is against any form o f financial strain on the already poor village folk with regard to the support o f their health delivery services and projects, M olina et al (1980), and Jancloes et al (1982), are in favour o f asking community members to contribute materially, financially or otherwise towards projects they have initiated. They however stress that the government should be apt to detect any dissatisfaction among the community members when they seem to have been unduely taxed. Samba's (1989) conclusions on PHC programmes seem to be the core o f this research. Writing on PHC in Gambia, he emphasized that it is relatively easy to organise village communities, get them to select village health workers, and even to train these workers. But the crunch came after the euphoria o f the honeymoon had passed - with the problems of remuneration, provision and funding o f drugs on a regular basis and continual evaluation and supervision. It is with this view in mind that the current study will attempt to identify factors affecting trained CHWs in the Nkoran District. 1.4 THEORETICAL FOCUS: Sttudies in the use o f traditional and modern medicine have focussed more on consumers o f these forms o f medicine with less emphasis on the structural components o f the health system and its social support system. Social scientists are now getting increasingly interested in the PHC approach to health especially in the third World. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 10 Social Science literature on PHC has seen a rapid growth since the declaration o f "Health for All" by the Year 2000 in May 1977 at the 30th World Health Assembly. The 1978 World Health Organisation United Nations International Children's Emergency Fund Conference on PHC in Alma-Ata, Russia, recommended that PHC should be considered the key to the achievement o f WHO's goal o f "Health for All" by the Year 2000. The Declaration o f Alma-Ata defines PHC as "essential health care based on practical scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage o f their development in the spirit o f self reliance and self-determination" (WHO: 1977). It is in this context that PHC becomes an instrument o f social change and development. Granted that primary health care systems can evolve from the economic conditions and social values o f specific communities, they nevertheless should have some basic components. Among these dre the promotion o f proper nutrition; an adequate supply o f safe drinking water; basic sanitation; maternal and child care including family planning, immunization against the major infectious diseases; prevention and control o f locally endemic diseases; education concerning prevailing health problems and the methods o f preventing and controlling them; and appropriate treatment for common diseases and injuries. Maximum community and individual self-reliance for health development are essential for the (PHC) programme to be operative at the community level. To attain such self-reliance requires full community participation in the planning, organisation and management o f PHC. Since PHC is an integral part both o f a Country’s health system and o f overall economic and social development, it has to be co-ordinated on a national basis with the other levels o f the health system as well as the other sectors that contribute to a country’s University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 11 total development strategy. PHC is thus an alteration in the medical system as well as an approach to rural development. Ian Robertson (1977: 539) sees social change as "the alteration in patterns of culture, social structure, and social behaviour overtime" (1977: 539). The justification behind the need to find an alternative health care delivery system to ensure "health for all" is simple. It is to meet the health needs o f majority o f the people more especially those classified as vulnerable children and pregnant mothers. To achieve this however needs an alteration in the hospital-based health care system. Such a simple conclusion fits into Toynbee's cyclical theory o f social change. The key concepts in his theory are those o f "challenge" and "response". According to Toynbee, every society faces challenges - at first, challenges from the environment, later, challenges from internal and external enemies. Toynbee concludes that the nature o f the society's responses determines its fate. To him each new civilization is able to borrow from other cultures and to learn from their mistakes. The achievements o f a civilization consists o f its successful responses to challenges; if it cannot mount an effective response, it dies (Robertson, 1977: 544). The argument being put here is that the acceptance o f the PHC concept and the use o f CHWs in rural areas in Ghana is a response to the challenges posed by the present health care delivery system. The limitations in the present health care delivery system which has been described as hospital-based and urban-centred and lessons learnt from other countries using community-based health workers to extend "essential health" care to their rural communities thus call for the response Toynbee talks about. It must be said here that each process which involves a new pattern o f behaviour, new attitudes, new techniques could be reffered to as an innovation. We may admit that innovation and acceptance o f innovation do not occur at random but depend on the urgency o f social needs, the degree o f disorganisation, as well as the flexibility o f society University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 12 and the degree to which change has been institutionalised. The more dynamic a society is, the more tolerant it is toward innovation. Thus whereas traditional societies actively suppress innovation, modern societies actively encourage it. Even here (in modern society) innovation encounters resistance, due to emotional investment in old patterns and distrust o f new ones. What is more, in the same society not all innovations stand an equal chance o f being accepted. In order to be accepted, an innovation must be in line with a society's needs and interests, and must be compatible with existing framework. Once an innovation is the society favourably judged, special divisions are devoted to its implementation and to promoting its acceptance in society. From the concept o f innovation discussed above, two main ideas could be derived to help in the current research. 1. The idea that innovation and acceptance o f innovation will depend on the urgency o f social needs and the degree to which change has been institutionalized; 2. Linton’s argument that innovation must be in line with a society's needs and interests and must be compatible with its existing framework. The PHC concept and the use o f CHWs in rural Ghana from the perspective o f the ODC/ILO (1976), can also be viewed as a development strategy approach. Here, various theories discussed by the two organisations, such as the "spontaneous process" models the “responsive-process" models, the "authoritarian top-bottom" approach, the "bottom-up" approach and the "holistic" approach to rural development come into play. Like the "trickle-down" theory of development the two organisations view the "spontaneous-process" models o f technical change as being automatic. Once technical change has begun, the models predict, it will spread on its own, like an "epidemic" True, some effort is required to produce the initial "infection” . But this effort need not be University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 13 greater than a little nudge. All that is needed is the initial adoption o f the relevant innovations by selected "change agents". Thereafter, in the fullness o f time "the epidemiological process" eventually takes over to ensure widespread and rapid diffusion o f those innovations. This in some way supports the Philosophy o f the hospital-based health care delivery system. Once a hospital is established in an area, it serves the outlying areas and is to bring about the needed improvement in the health conditions o f the people not only in town where the hospital is based but also in the hinterland. The argument also supports the "Growth Centres" Concept o f rural development. Francois Perroux, the well-known French regional planner, mentioned that development does not appear everywhere at the same time. It manifests itself with variable intensities at favoured points, from which it tends to propagate outside with variable final effects for the economy as a whole. These points from which the development activities radiate to the outside territories are the nodal points o f development - the "Growth Centres" "This is also the trickle-down" process o f development. The original theory o f socio-economc development that accompanied the post - 1945 decolonization o f Asia and Africa rested on the idea o f modem society as the goal o f development. Modern society supposedly had typical social patterns o f demography, urbanization and literacy, typical economic patterns o f production and consumption, investment, trade and government finance; and typical psychological attributes of rationality, assumptive identity and achievement motivation. The process o f development consisted on this theory, o f moving from traditional society, which was taken as the polar opposite o f the modem type, through a series o f stages o f development derived essentially from the history o f Europe, North America and Japan -to modernity that is, approximately the United States o f the 1950. After their political independence there was, understandably something about this mode which few African countries could resist Here were models that promised the newly independent countries rural transformation within a few years. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 14 Reality proved perverse, however, and few o f the programmes that enacted these models in Africa were successful. Target Communities proved to have an uncanny tendency to ignore innovations introduced in this way, even, when the superiority o f these innovations over traditional practices were clearly beyond dispute. In time, the African countryside came to be littered with the remains o f innovations which had died before adoption. Certainly, they could not be held up as proof o f the spontaneity o f technical change. The health system established by the colonial government and subsequntly followed by successive nationalist Governments has not brought about much improvement in the over-all health conditions o f the rural masses. On the other hand, responsive-process theorists see a possibility for intervening in technical change decisively to facilitate it. Technical change, they hold, could be brought about through a judicious manipulation o f certain external factors. In this connection, considerable efforts have been made at both theoretical and empirical fronts to identify these factors and to ascertain their exact roles. The PHC concept in this sense fits into this general concept since some kind o f intervention is instituted. In recent years, debates on rural development have on many occasions emphasised more on the source o f the innovation. In this respect, three strategies may be distinguished, depending on whether what is advocated is manipulation o f those factors from the “top", "bottom" or from "both ends". Macro-strategies consider it appropriate for governments to choose the goals and specific objectives o f technical change as well as the means and specific programmes for attaining them. In these strategies, initiatives are taken at top levels, translated into appropriate directives -again, at the top and then transmitted through the intermediate layers o f the local bureaucracy down to the public for implementation. If one considers the PHC concept from its Alma Ata Conference through national programmes to the community level, it will be appropriate to see it as a top-bottom approach to health development. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 15 Strategies that advocate manipulation o f the factors o f technical change from the bottom see the role o f governments as being not that o f initiator but that o f facilitator. The role o f initiator is reserved for the people, who are the "subject", not “object” o f development. They participate in development actively, not passively, and initiatives are taken by them at the bottom, not by government bureaucrats at the top. This arrangement is favoured for various reasons. Sometimes equity is stressed, and bottom-up approaches are favoured because they minimize cost and generally "democratize" national development. At other times special strengths are believed to lurk at the bottom, and bottom -up approaches are advocated because they tap them use them as a basis for technical change. A World-Bank president has declared, "there is no more powerful force for progress against poverty than the initiative and ingenuity o f the poor themselves". At other times still conceessions are made to the "numbers" o f the rural mass, and bottom-up approaches are advocated because moving that mass is thought to be easier when internal forces are mobilized for that purpose than when external forces are exerted to that end. The idea o f making the people the initiators o f their own health programmes to bring about the much needed development supports the above argument. Finally, there are stn tegies which see the distinction between top and bottom as forced. They consider the to > and the bottom to be "holistically" one: the top is no more than the end o f the botto n and the bottom no more than the beginning o f the top. Likewise, the division ci technical change into innovation and diffusion is considered artificial: diffusion is integral to innovation, because technologist must anticipate diffusion at the innov don stage. This means that the top must work together with the bottom: the innovato must co-opt the user o f his innovations into the designing o f those innovations. From nis angle, PHC becomes, a holistic approach to both health care delivery and rural ievelopment. In recent ye' rs, especially since the early 1970s, there has been an increasing interest in participator ipproaches to development. This interest is manifested at both the national and the ir ernational level. At the international level, most multilateral and bilateral University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 16 agencies have recognized the importance ot participation both as a means and as an objective o f development. Participatory development here assumes a wider interpretation than mere increases in labour productivity, declining share o f agriculture in total output, technological progress, and industrialization with the consequent shift o f population to urban areas - economic growth. Here development objectives concentrate on such indices o f living standards as income distribution, nutrition, infant mortality, life expectancy, literacy education, access to employment, housing, water supply and similar amenities. A farther view o f participatory development puts the spotlight on human potential and capabilities. According to this view, development is seen in such terms as enhanced competence to analyse and solve problems o f day-to-day living, expansion o f manual skills and greater control over economic resources, restoration o f human dignity and self-respect, and interaction with other social groups on a basis o f mutual respect and equality. The agents to carry out this system are the CHWs who are to be supported by the rural masses. Participation as used in the PHC system and the CHW programme can be said to cover three main areas: 1. It refers to the "mobilization" o f people to undertake social and economic development projects. Typically, the projects are conceived and designed from above and the people are "mobilized" to implement them. Their participation thus consists o f their contribution o f labour and materials, either free or paid for by the authorities (Griffin 1990). 2. The second interpretation equates participation with decentralization in governmental machinery or in related organizations. Resources and decision-making powers may be transferred to lower level organs, such as University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 17 local officials, elected bodies at the village or country level or local project communities. 3. The third view o f participation regards it as a process o f empowerment o f the deprived and the excluded (Gran. 1983; Oakley, 1987; Oakley and Marsden, 1984). One fact o f empowerment is the pooling o f resources to achieve collective strength and countervailing power. Another is the enhancement o f manual and technical skills, planning and managerial competence and analytical and reflective abilities o f the people. It is at this point that the concept o f participation as empowerment comes close to the notion o f development as fulfilment o f human potentials and capabilities. On one hand, the CHW programme can be described as a conventional development project. According to Griffin et al (1990), a conventional development project is conceived and designed from outside by national and international experts, together with the paraphernalia o f pre-feasibility and feasibility studies, appraisal reports, specification o f inputs and outputs, calculation o f internal rates and sophisticated cost-benefit analysis. The writers mention that the people for whom all this is supposed to be done exist only in the abstract as numbers whose output and productivity are to be enhanced and whose "needs" are to be satisfied. Their participation in the preparatory phase if they are lucky, may, at best, consist o f some hastily organized meetings with the experts and bureaucrats at which they are "briefed" about the objectives and activities o f the planned projects. In the implementation phase they are expected to carry out their pre-assigned roles", (p.226). The CHW programme can also be said to be a participatory development project. Its central concern is with the development o f the moral, intellectual, technical and manual capabilities o f individuals. The CHW programme in rural areas is therefore, regarded as a process for the expansion o f these capabilities with CHWs as the pivot around which the programme is to revolve. The above, discussions provide theoretical perspectives from which clear research University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 18 interests on various aspects o f CHWs in the PHC programme have emerged. 1.5 FIELD METHODOLOGY Sampling: Looking at the focus o f the current thesis, that is, factors affecting CHWs, the target groups o f the study included the CHWs themselves, and the two agencies (the Community and the MOH) whose activities are assumed to be affecting the functions o f the CHWs. The first problem that had to be tackled was the determination o f the sample frame (i.e. to establish the number o f CHWs that had been trained in the area). The second was the determination o f the size o f the sample. The frame was provided by the 1989 Health Services Report o f the St. Theresah's Hospital, Nkoranza. The distribution o f CHWs within the district was given as in Table 1.2 Distribution of Community Clinics bv Status as of the Survey Data Status of Community Clinics Inactive Active Temporary Permanently Newly Trained Bomiri Boabeng Dromankese Tom Bonsu Asuano Busunya Koforidua Anama Dotobaa Bredi Kyekyewere Ahyiayem Kranka dotobaa Senya Dromomankuma Donkro Nkwanta Akonkoti-Dumasi Ntanaso Asuano Jerusalem Boabeng SOURCE: Nkoranza CHW survey. 1990: Missing from the report were the names o f communities which could not establish clinics for their CHWs. This had to be soughted from the CHW themselves. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 19 Based upon the above data the CHWs were categorised into three main groups: a. Those operating clinics (i.e. those functioning) (12) b. Those who established clinics but had collapsed (10) c. Those CHWs that could not establish clinics (10). Included in the last group are the five awaiting the commissioning o f their clinics. Opinion leaders (Community Development/Health Committee members) from the Communities categorized above were also included in the sample. These are the people who are supposed to lead their people to undertake development programmes including health. They would therefore know the nature and extent o f involvement o f their Communities in the CHW programme. The health authorities are expected to be in-charge o f the training o f the CHWs. They are also to supervise, provide referral points and refresher courses for the CHWs. Their inclusion in the Sample is thus considered important as this is expected to provide some, if not most, o f the health related factors affecting the functions o f the CHWs. Some health authorities at Kintampo health centre, St. Theresah's Hospital, Nkoranza, Yefri Health Post and Nkoranza Health centre were thus interviewed. They included: a. The Medical Officer in-charge o f the Kintampo Health Training school. b. The Medical Officer in-charge o f the Kintampo Health Centre. c. Medical Officer in-charge o f St. Theresah's Hospital, Nkoranza. d. The Health Centre Superintendent at Nkoranza Health Centre. e. The Officer in-charge o f the Yefri Health Post. f. The District Medical Officer (DMOH), Nkoranza. g. The PHC District Co-ordinator, Nkoranza University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 20 Data Collection Instruments Data collection from opinion leaders in the communities selected included the use o f self-administered questionnaire, focussed group discussions and oral interviewing methods. Guestions covered issues like; 1. The nature and extent o f community involvement in the planning and implementation o f CHW programme. 2. Problems facing communities in playing their expected roles and; 3. How the functions o f CHWs could be strengthened. To determine the characteristics o f CHW training and how these are affecting the operations o f CHWs within the district, information was sought from the existing health institutions. Here a guide [checklist] was used. This was to help in the identification o f any areas o f deviations and omissions between what CHWs were supposed to do and what they are doing in their communities. Structured questionnaires were used to obtain information from Community Health Workers (CHWs) about; a. Selection procedures; b. mode o f training; c. their financing during and after training d. sources o f supply o f inputs; e. regularity o f the supply of inputs; f. remuneration g. CHWs perceptions and experiences about their work and how these are affecting them h. what they deemed to be factors responsible for their successes and failures; and 1. how their work could be strengthened. Documentary records from the Ministry o f Health [MOH], books, journals, papers, reports from workshops and seminars related to the topic were used extensively. Also University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 21 sought from MOH were information on the PHC programme in Ghana and the establishment o f the Kintampo Project. Operational Definitions of Concepts 1. Community Health Worker (CHW) is used throughout this paper in a generic sense. Many countries and programmes call such workers by different names, including: Family Welfare Educator (Botswana), Community Health Agent (Ethiopia), Rural Doctor and Health Aide (China), Community Health Guide (India), Community Health Aide (Jamaica), Village Health W orker (Nigsria), and Barangay Health Worker (Philippines). In Ghana they are either called Community Health Workers or Community Clinic Attendants. 2. Primary Health Care Programme: According to the Declaration o f the International Conference on PHC, PHC is a means o f providing "Essential Health Care to all individuals through their first level o f contact with a national health service". This is the meaning applied to PHC i.n this work. 3. Community Participation We do not simply mean the mobilization o f the peoples to generate resources - money, labour, and materials for government -planned and - Controlled programmes, but also as a process through which the people gain greater control over the social, political, economic, and environmental factors determining their health. In specific terms community participation should not only stop at the implementation stage but in the involvement o f the people at every stage o f the health programme, such as initial assessment o f the situation, defining the main health problems setting the priorities for the programme implementing the activities monitoring and evaluating the results, etc. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 22 4. Success o f the CHW Programme This will be assessed by the Existence o f the following: a. A community-owned clinic b. The premises used for the clinic should have been built or hired by the community. c. The CHW is supervised by the Community and the MOH d. Drugs and other inputs to the clinic is supplied by the community e. The CHW is rewarded by the community. Failure o f the programme will be the absence o f the above. FTELD PROBLEMS Three (3) main problems were encountered: a. The first dealt with the inaccessibility o f some o f the roads due to heavy rains. This made many o f the feeder roads in the district unmotorable and thus difficult to use more especially as the researcher used bicycle. This delayed the work initially. b. The second problem was the difficulty o f meeting the CHWs who had dropped out in their communities. Some drop-outs had travelled outside their communities. Several visits had to be made into some o f the communities before those CHWs concerned could be contacted. c. The final problem was encountered during the focus group discussions. M ost o f the opinion leaders were not committee members when the CHWs were trained and did not know much about the background o f the trainees and the programme. Some could thus not respond well to the questions. In such situations, discussions were monopolized by those who were members o f the committees concerned. In two villages, some former committee members had to be invited. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 23 Limitations in the Study a. The intention o f the researcher was to record the focus group discussions. This would have made it possible for proper analysis to have been made since the whole discussions could have been replayed to detect omissions and misinterpretations or distortions o f facts. This could not be done as some opinion leaders objected to the use o f the tape recorder. It is possible that much useful information was lost as the researcher had to play a dual role o f secretary cum facilitator. b. Due to lack o f time and financial constraints, the research could not be extended to cover the majority o f the villagers. Data collection in the communities was limited to only the opinion leaders and the CHWs. If the ordinary people had been covered, it is possible that different views might have been shared on some o f the major issues raised in the research. The people would have been the best informants on why they bypass the Community Clinics, why they refuse to help the CHWs in their farms and how best they think the programme can be re-organised to meet their desires. c. No initial contacts were made with the Communities to inform them about the research. The opinion leaders were thus unaware o f the arrival o f the researcher. Unfortunately visits to some o f the communities were in the late mornings and early afternoons. These were the times when most people had either places o f work. W hilst some opinion leaders who know something about the establishment o f their community clinics were missed completely as a result o f this, others had to be rushed into the meetings. Such invited people usually had divided attention. In two villages, Ayerede and Bonsu, the CHWs had to be invited in the middle o f the interview to attend to emergency cases. W hilst the CHW at Ayerede had to attend to a pregnant woman who had collapsed in the church house, the CHW at Bonsu had to leave the interview to attend to a boy with convulsion. Through these interruptions, information flow was usually disrupted. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 24 The enthusiasm o f the opinion leaders in talking about their clinic - "hospital" to somebody from "the University" in Accra tuned them towards something positive. They saw the fulfillment o f their long - awaited desire o f getting a clinic at hand. This influenced their answers to some o f the questions especially those on selection and financing o f CHWs. If this research is to be done again, the following will be useful: a. The research should be done in more districts for proper understanding o f factors affecting CHWs in rural Ghana. b. The research should seek the opinion(s) o f the rural masses who are the users o f the services o f the CHWs. This is hoped to provide useful information to planners in terms o f how the people themselves see the programme, and what contributions they can make to it. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh C H A P T E R TWO THE HISTORICAL DEVELOPMENT OF THE PHC AND CONCEPT IN GHANA This chapter takes us into the history o f PHC programme in Ghana. To provide an appropriate framework for such a discussion, examination is made into the history o f the Health Services in Ghana. The limitations in scientific medicine in terms o f coverage and cost is highlighted. In the latter part o f the chapter, the Kintampo Project where Community Health Workers (CHWs) in the Nkoranza District receive their training is discussed. Reference is also made to the role expectations and duties o f organizations involved in the programme as stated in the programme's documents. This is done with the aim o f identifying areas o f omissions, deviations and shortcomings in Ghana's attempt to implement the PHC programme at the community level. 2.1 GHANA'S CONVENTIONAL MEDICAL MODEL The health services o f this country have emerged from the small beginnings made by the colonial powers in the early 19th Century (Sai, 1966). There is no doubt that Western style medicine as it existed in Europe was introduced into the country with the merchants and explorers from the 15th Century onwards (i.e. from 1471 when European explorers landed on the Coast for the first time). The period between 1471 and 1844 which is described as the first phase o f the.development o f colonial medical services was also significant in European history. It was then that Louis Pasteur's "germ theory" or "Contagionism" revolutionalised medical thinking. With this theory, the individual was atomised and cured. The theory ensured that health problems would be individualised. Here, unlike the social causation theory where the individual is treated as a whole with no separation between body and soul, the focus o f the germ theory is on the biological organism. The germ theory is thus reductionistic and particularistic (Twumasi, 1975). 25 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 26 However, it was not until 1867 that what can be called an official medical report was written by Or. Thomas. One year after the report, the first hospital in the country was established in Cape Coast and in the same year a medical report was made to the Colonial Secretary recommending the appointment o f a medical officer o f health. By 1895 medical institutions in the country had increased to 10 and a medical department was established. The personnel o f the department were to be found in Accra, Ada, Cape Coast and Saltpond which were the main ports and trading centres at the time. In 1902 there were about 10 12 doctors in the whole country. Later in the year, the medical staff in the West African Colonies o f Britain were amalgamated into the West African Medical staff. The idea was that the bigger unit would make for easier recruitment and flexibility in posting staff. In this early state o f colonial health services, all the effort o f the medical department was focussed on the health o f the European personnel. The strategy took two forms; treating them promptly when attacked and segregating them from the indigenous population into specially reserved quarters in the big towns to reduce contact with infected natives. The latter policy was considered necessary because the explorers and the colonial administration had found the country beset with many communicable and preventable diseases (Sai, 1972). This fact was made clearer by Simpson in 1909 when he noted that: "The policy has been to provide a European quarter in order that the risk o f malaria infection from the insanitary conditions o f native houses and from infected natives may be reduced". Later it was realised that the health o f the expatriate population could not be completely safeguarded simply by segregation and by prompt treatment alone since diseases can be transmitted from those people living in the vicinity o f the Europeans. Therefore, some measure o f environmental sanitation and water supplies were undertaken in some o f the big towns and medical care was gradually extended to the indigenous people especially those who were working as civil servants or as house staff to the Europeans. Others who did not come within this category could have medical attention but it was entirely left to the medical personnel whether they would charge for such servicec or not. M uch later, University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 27 however, the medical department accepted responsibility not only for expatriates but for the population as a whole as far as it was able to. Disease control as opposed to simple diagnosis and cure o f a sick individual was also accepted as part o f the responsibilities o f the medical department. But preventive aspect o f the work was given priority. The acceptance o f disease control as part o f the responsibilities o f the medical department led to the initiation o f some projects and organisations which made useful contributions to the improvement o f health in the rural areas. The introduction o f arsenicals which "miraculously" cured yaws with only a few injections provided health workers with a most useful entry tool into the community. The success o f this demonstration is responsible to some extent for the love o f injections demonstrated by most patients today. Compulsory smallpox vaccination was introduced in 1920. Before this a small unit had been formed to control trypanosomiasis. However, the unit was disbanded during the 1914 - 1918 period and was re-established in 1929. The original trypanosomiasis unit was centred in Gambaga in the Northern Region. It was later enlarged and ths headquarters moved to Kintampo. By independence, the colonial health system had developed certain features which were inherited by post colonial governments. These include: 1. A strong curative and urban bias; 2. A centralised medical administration with less activity in the rural communities; 3. Central government as the largest provider o f health services (this became more strengthened in the postcolonial administration after the creation o f the M inistry o f Health (MOH) to be in-charge o f all public hospitals and health centres). 4. The creation o f government support system to compete with traditional healing system. 5. A gross North-South disparity in the provision o f health care services and facilities with the southern half o f the country as the greater beneficiary. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 28 Four conditions have been identified as the root cause o f this situation: i. Emphasis on the construction o f facilities rather than the provision o f services; ii. Over-sophisticated training with emphasis on specialized hospital-based services for the few, rather than preventive and promotive services for everyone. iii. Poor and unequitable deployment o f health staff. iv. "top-down" health care delivery system with a noticeable lack o f co-ordination with other sectors (social welfare, community Development, Water and Sewerage, Agriculture etc.), and little or no community involvement. By 1956, all the health services were in the regional and some district capitals. Commenting on the rural-urban disparity, the Easmon Committee Report notes that the rural areas have been neglected. The report added that the preventive emphasis o f health has not been taken seriously and that one adult in every three normally dies from preventable conditions. Sai (op cit) supports this when he observed that the number and distribution o f hospitals and clinics were such that they could not offer any kind o f services to more than at m ost 20 percent o f the population. The 20 percent were mostly the urban dwellers. By 1973, majority o f the doctors in Ghana were working in the urban centres. W hilst nearly 82% o f the 688 doctors in Ghana were based in urban centres with population o f about 20,000, the others were in communities with population between 5,000 19,000. (Republic o f Ghana 1975/76 -1979/80 Part II). Surpringly one finds a situation where most o f the rural communities have populations o f less than 1,000. The problem as later demonstrated by Adjei et al (1989) is not the distribution of doctors per se, but the effect o f this situation on the doctor population ratio for the regions and the districts. While the national average in 1985 was given as 1:10,000. In some regions, notably in the North, the ratio was as low as 1: 44,792 while that o f Greater Accra region, with 42.5% o f the country's doctors, was 1:4,458. Brong-Ahafo had 1:24,132 and Nkoranza District where the research was conducted had 1:83,821 (Ministry o f Health: 1985). University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 29 Touching on the unequal distribution o f hospitals in the country, Ewusi in 1978 estimated that Greater Accra with about 9.4 percent ot the total population had 47 percent o f total government doctors, 34 percent o f hospital beds and 12.2% o f all hospitals in the country. The nine regional capitals (counting the two Upper Regions as one as at that time) with only 15 percent o f the total population o f the country had 55.4 percent o f all hospitals in Ghana and 51.2% hospital beds. There can be no doubt that such mal-distribution o f hospital facilities and personnel will affect health sector expenditure. Analysis o f health sector expenditure for the period 1976/77 1988 is done with the view o f identifying the specific health sub-sectors that receive more attention. This portrays the orientation o f health services. In the past ten years the supportive services o f the health sector has been allocated the highest portion o f the recurrent expenditure (see table 3.1) Except for 1983, supportive services had always been allocated approximately 50 percent o f recurrent resources. The components o f the supportive services include general administration, manpower, medical equipment and materials and research into plant medicine and other services related to health care delivery. Over the same period, the curative subsector was scarcely allocated resources up to 40 percent o f the recurrent resource except in 1983, when the subsector was allocated up to 47.6 percent o f the year's resources. For the period under consideration, promotive and preventive health had always been allocated the least o f financial resources. Until 1987 preventive health always had approximately 10-14 percent o f the resources. The point here is that the rural majority who are served largely by non hospital based health delivery system have once again been neglected in the area o f the allocation o f recurrent resources with primary health care attracting least attention. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh This is demonstrated in table 2.1 below: RECURRENT HEAI TH EXPENDITURE BY SUBSECTOR (gQOOn977/78 - 1988^ 30 SUPPORTIVE SERVS. CURATIVE SERVS. PREVENTIVE SERVS. TOTAL YEAR AM OUNT % AMOUNT % AMOUNT % AM O UNT % 1977/78 96,639 43.5 92,074 41.4 33,632 15.1 222,345 100.0 1978/79 164,328 49.9 124,953 38.0 39,767 13.1 329,048 100.0 1979/80 137,468 48.0 114,554 40.0 3,400 12.0 286,022 100.0 1980/81 172,926 50.8 127,314 37.4 40,162 11.8 340,452 100.0 1981/82 255,127 49.0 206,306 39.0 62,214 12.0 523,649 100.0 1982/83 232,273 38.5 288,130 49.6 84,104 13.9 605,207 100.0 1984 1,295,026 66.0 515,000 26.4 143,806 7.4 1,953,884 100.0 1985 1,609,000 50.0 1,267,442 39.0 367,435 11.0 3,343,877 100.0 1987 3,412,057 49.5 2,768,125 39.8 741,764 1.7 6,951,946 100.0 1988 4,965,143 50.5 4,494,485 45.7 372,931 3.8 9,832,559 100.0 SOURCES: (i) MOH Health Sector Annual Estimates p.2 (ii) MOH. Planning Division. In 1988, supportive servicss had the highest allocation o f 50.5% while the curative health accounted for 45.7%. The lowest allocation o f the recurrent expenditure o f 3.5% went to the preventive health services. From table, 3.1, it could be seen that whereas allocation o f resources to supportive and curative health subsectors increased from 1987 to 1988 there was a considerable decrease in both the amount and real value o f the resources allocated to preventive health. In 1987, 7.4 million cedis was allocated to preventive health and in 1988, the amount had University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 31 declined to 3.7 million cedis. This points to the nature and interest o f government health care services in terms o f the allocation o f resources (recurrent expenditure). The pattern o f health sector expenditure gives an indication o f the orientation o f the health services in Ghana. A meagre proportion o f resources was allocated to promotive and preventive health. Emphasis on curative health has consistently been expanding. Also manifested are increases in supportive sector expenditure. The implication o f heavy investment in curative health and allocation o f substantial health resources to supportive service is likely to exacerbate the already deplorable health conditions o f the rural areas. M ost o f the health facilities are allocated in the cities and a few bigger urban centres. This points out that little change i f any was made in the health care delivery system by the system that was inherited from the colonial government. The limitations in Ghana's health care delivery system as discussed above could perhaps help one to argue for the need for a more equitable system. There are however other international and issues which go to strengthen the argument better. 2.2 DISILLUSION WITH THE MEDICAL CARE MODEL In the mid-1960s King's (1966) widely disseminated book in Europe articulated a different approach to health services, particularly in Africa. The book reflected many people's concern about the inappropriateness o f the Western model o f medical care being imposed on, or copied by, developing countries. It also reflected a general disillusionment with purely medical solutions. In spite o f enormous inputs, many mass disease control programmes were failing for both technical and organisational reasons (Cleaver 1977). Even though there were successes, like the reduction o f yaws, the control o f malaria in some areas, and later the eradication o f small pox, the major debilitating or killer d iseases__such as tuberculosis, gastro-enteritis and m easles___continued to take University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 32 their toll. Many development projects, such as irrigation schemes or feeding programmes, had had the unintended consequences o f actually causing more diseases (Targhi Farver and M ilton 1973). There were no "medical" solutions for malnutrition, a major complicating condition in many children illness. It was clear that other solutions _ social, educational, economic and po litica l _ had to be sought. King (1966) emphasised the importance o f looking at the community's needs, arguing that health services and training should be culturally based. In order to increase access to health services the use o f medical auxiliaries was strongly advocated and a general attitude was that appropriate technologies should be developed. It was during the mid-1960s that the idea o f "basic health services" was developed, advocating the further extension o f peripheral health centres and dispensaries improving access by taking services to where people lived. The basic health services policy paved the way for the PHC approach, by recognizing the inappropriateness o f hospital care for many o f the health disorders that were being brought to hospitals. Furthermore it was acknowledged that many sick people lived too far away to get to hospital in time for effective treatment. Therefore it was argued that basic health services should be available, accessible, acceptable and appropriate. The medical profession's monopoly o f knowledge was closely examined; dissatisfaction was being expressed with the private medical systems. Concern about the rising costs o f medical treatment added weight to the doubts expressed about health systems in general. All these issues served to raise questions about the medical diseases and medical care models, and to shift health care from professionals The issues were o f course, just as relevant to the Third World. The importation o f expensive and sophisticated technology and training programmes to deal with relatively rare conditions in developing countries represented a disproportionately high part o l national health budget. Further, it was clear that sick people sought help and recovered not only from Western trained doctors but also from a variety o f sources ( Kleinman and University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 33 Sung 1979). The "Witchdoctor" slowly became the less pejorative “traditional" or “indigenous" practitioner and traditional midwives were recognised to be doing useful work in their communities. Thinking was thus shifted to not only PHC but the use o f CHWs and what was "Medical" care increasingly became "health" care. M uch o f the debate that followed centered around the diffusion o f technology; how, and why, independent countries retained colonial health infrastructures, and aspired to ideals that were inappropriate to the health needs in their own countries. Banerji (1974) suggested that the inappropriateness o f selection and training had alienated health W orkers from the people they served. The costly emigration o f newly graduated doctors to the Western developed world was indicative o f a professional identification reinforced by inappropriate training, as well as the pull and push o f market forces. Pharmaceuticals also came under scrutiny for several reasons Including poor prescription habits, and the plethora o f brand-named drugs which added to the costs qf£ many countries’ health services. 2.3 CHANGING TDEAS ABOUT POVERTY. HEALTH AND DEVELOPMENT This changing attitude emanated from the developed countries as a guide to economic and social policy in the newly independent countries o f the Third World. Early post-second World War development theories had stressed spontaneous process models o f change. The assumption made was that, through industrialisation, the less developed countries would become "developed" in the sense o f having high per capita national incomes. Implicit in this assumption was the belief that the benefits o f growth would "trickle down" to the rural areas. This seemed to be the path of development taken by Ghana after independence especially when it adopted the Import-substitution Industrialisation policy. This policy saw health and other social services such as education as non-productive consumption sectors. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 34 By the late 1960s and early 1970s there was growing scepticism as to who was benefitting from development. In many countries with high rates o f economic growth, the rapid rise in per capita income was firmly concentrated in the hands o f a fairly small group o f people and the majority were worse off than they were before. The "miracle" o f the "Green Revolution" (increases in agricultural output based on high yielding varieties o f cereals) had actually led to no improvement in the productivity and income o f poor farmers, but rather to increasing marginalization o f subsistence farmers. One o f the common explanations for poor countries' slow rates o f development was rapid population growth which led to the dissipation o f the benefits o f the economic growth because it had to be divided among increasing numbers. In the 1960s and early 1970s it was increasingly accepted (although not everywhere) that population control (or family spacing) should integrated into maternal and child health (MCH) services. It was perhaps the International Labour Organization [ILO] W orld Employment Conference in 1976 that most clearly rejected past strategies for development and identified a new priority based on the eradication o f poverty, the provision o f basic needs and productive employment for the potential labour force. The ILO Conference turned from a narrow focus on jobs to basic needs, with minimum targets set for food consumption, clothing, housing and the provision o f essential services in the areas of water, sanitation, education, health and public transport ODC/ILO 1976). It thus became more acceptable to see health as integral component o f development. Consequently, contrary to tradition, the World Bank began direct lending for health programmes in the 1980s (World Bank 1980). The WHO started viewing health not only as the absence o f disease but also as the complete physical, mental and social well-being o f the individual. There was thus a search for a new health care delivery system to cover all the aspects that affect the University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 35 peoples health. This search fell on PHC. Two international organisations in particular promoted the PHC approach, WHO and UNICEF, the latter initially playing the supporting role to the health professionals. The 1978 public launching o f "PHC" at A lm a A ta a vehicle for "Health for all by the Year 2 0 0 0 " was the result o f long discussions about policy in both organisations. In the early 1970s many people within WHO or connected with the organisation felt that basic health services were not keeping pace with changing population size and structure either in quantity or quality. This led to the setting up o f a special WHO working group whose terms o f reference was to examine the basic health services concept and the vertical disease control programmes. The working group {WHO 1973} reported that: "There appears to be widespread dissatisfaction o f populations w ith their health services.....such dissatisfaction occurs in the developed as well as in the Third World" Among the enumerated reasons for such dissatisfaction included: i. Failure o f health services to meet people's expectations; ii. Inadequate coverage; iii. Great differentials in health status within and between countries; iv. Rising costs; and v. A feeling o f helplessness on the part o f the consumer who feels (rightly or wrongly) that the health services and the personnel within them are progressing along an uncontrollable path o f their own which may be satisfying to the health professionals, but which is not what is most wanted by the consumer. The two main effects o f this report on the development o f PHC were conceptual, and promotional in nature. Conceptually the report laid the basis for the PHC approach.. It emphasized the need to involve the consumer in order to tap local resources, to "make medicine" belong "to those it should serve" and called for a "national will" as well as "international will" University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 36 for positive health. Promotionally, the report drew attention to WHOs role as "world health conscience". As part o f the search for new solutions to problems in health services, the W HO/UNICEF Joint Committee on health policy commissioned a study o f successful programmes using alternative strategies for providing health care. A number o f countries, and many non-governmental organisations, had been experimenting with new ideas in health service delivery, including the Christian Medical Commission. Drawing on these health care materials it was possible to identify a number o f radical approaches to traditional health delivery systems which seemed to offer hopeful alternatives. The WHO began to take a more active role in the persuasion and promotion o f a new health message. In 1975, the Director General o f the Organisation, Halfdan Mahler, launched the idea o f "Health for All by the Year 2000" as WHO's contribution to the UN's New Economic Order. The philosophy meant an action to achieve an acceptable level o f health evenly distributed throughout the World's population. The message was that, health had to be considered in the broader context o f its contributions to social development. It was in this climate o f ideas {and preceded by a number o f national and regional meetings on PHC) that the international conference on PHC was held at Alma Ata in 1978. From the meeting, attended by representatives o f 134 governments and sixty-seven international organisations, came twenty-two recommendations {WHO/UNICEF 1978}. The Declaration o f Alma Ata outlined the role o f PHC. Community Health Worker (CHW) programmes were seen as one ot the strategies for the programme. In the Alma Ata document produced after the conference, the rationale behind CHWs was clear: For many developing countries, the most realistic solution for attaining total population coverage with essential health care is to employ CHWs who can be trained in a short time to perform specific tasks. They may be required to carry out a wide range o f health care activities, or, alternatively, their functions may be restricted to certain aspects o f health c a re .......... In many societies it is University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 37 advantageous if these health workers come from the community in which they live and are chosen by it, so that they have its support (WHO/UNICEF, 1978). According to the WHO, "Primary Health Care addresses the main health problems in the community providing promotive, preventive, curative and rehabilitative services. The organisation acknowledged that the PHC services will vary from country to country and from community to community in the same country, however they should include: a. Promotion o f proper nutrition b. an adequate supply o f safe water and basic sanitation c. maternal and child care, including family planning d. immunization against the major infectious diseases e. prevention and control o f locally endemic diseases f. education concerning prevailing health problems and the methods o f preventing and controlling them g. appropriate treatment for common diseases and injuries and h. provision o f essential drugs. The strategy o f the system is directed towards three aims: a. to improve the accessibility (coverage) o f health services by putting up a village based system to obtain essential basic services rather than for a few to receive sophisticated care b. to improve the quality o f primary health care at the point where it is most needed in the village and peri-urban areas by retraining and redeployment o f PHC personnel. The aim will be to meet priority health problems o f all the people c. to improve and strengthen the management capacity to support the primary health care system at all levels. The aim will be to make more effective use o f existing resources. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 38 The proposed system will have services provided at three levels, namely Level A or community level, Level B or local council sub-areas and Level C or the district level. Level A {Community}These are areas with populations o f 200 to 5,000. The communities will be encouraged to select their own health workers and also compensate them. Training and continuing technical supervision will be provided by the MOH personnel.. The functions to be performed by the Level A workers will include primary preventive and promotive procedures, simple first level curative measures w ith emphasis on pregnancy, management, child health promotion, environments, sanitation and mobilization for health-related community procedures. Level B {Local council sub-areas} These will be the first referral point from Level A and will besited within 8 kilometres (5 miles) o f each Level A. The responsibilities o f Level B will include: a. technical supervision o f Level workers b. b diagnosis and treatment o f persons referred from Level A c. c giving o f immunization to infants and children at Level A d. identification o f pregnant women at high risk e. communicable diseases control activities f. advise on waste and faecal disposal and water and flood protection g. the collection and tabulation o f data from the Level A workers, and h. operational planning and liaison with local community leaders and the District (level C). The district will be the key level for the PHC system and willserve as the base for planning, management, supervision, hedlth data collection and analysis, budgeting and financial control o f the health services in the district. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 39 It was suggested that the key person in any scheme for PHC in theThird W orld must be the Community Health Worker. To enable scattered populations o f these extensive and still essentially rural countries to be served, substantial numbers o f such workers will be needed. According to the WHO Guide referred to above, the worker will be "a man or a woman who can read and write, and is selected by the local community authorities or with their aggreement, to deal with the health problems o f individual people Ithe community. Employment might be full or part-time.Remuneration could be either in cash or kind, and o f the local community. There should be room reserved exclusively for this work {WHO, 1977, p.3} The latter suggestion brought to focus the idea o f community involvement in its own health care. This idea was taken from experiences in China during the 1970s. What inspired people about the Chinese system was the active interrelationship between the barefoot doctors and their ommunities, and the claims o f success o f mass mobilisation gainst endemic and preventable diseases such as schistosomiasis. N ot only were barefoot doctors apparently offering health cars to rural populations never before reached by formal health services, but they were accountable to and controlled by their own community through the co-operative financial schemes. These allowed them to work in the fields part-time, and provide treatment part-time. By the mid-1970s there were instances o f ordinary village people receiving a short training and returning to their own villages to deliver a rudimentary primary health care services {Newell 1989}. Around the same period (Mid 1970s), there was also increasing acknowledgement o f community resources: traditional midwives were still delivering most babies with mothers and mothers-in-law giving advice. Anthropological studies added to the general knowledge that many health actions taken by people themselves were reasonable. This changing emphasis was accompanied in the industrialised world by the movement in favour o f self-care and support networks, and increasing awareness about lifestyle effects on health. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 40 It is this philosophy o f finding an alternative for the hospital-oriented and urban based medical system that will cover the rural majority and that will make health an aspect o f social development with the full participation o f the people it is to serve that Ghana accepted and implemented it. It is necessary therefore to look at the background o f Ghana's PHC system and the CHW programme. 2.4 THE DEVELOPMENT OF THE PHC PROGRAMME IN GHANA: THE KINTAMPO PROJECT In the 1970s it became clear to health policy makers in Ghana that something radical had to be done for not much impact had been made on the health o f the people despite the huge financial outlays since the 1960s. The thinking was that since the rural areas especially experience the highest mortality, morbidity and fertility rates, an integrated approach to rural health problems would be most appropriate. In view o f this a rural health and demonstration centre in Ghana was established in 1965. A t that time the Government o f Ghana in collaboration with the University o f Ghana Medical School {UGMS} approached the United Nations Development Programme {UNDP} for assistance to develop such a scheme. Although the proposal was acceptable, it was not possible for UNDP to assist immediately because o f national priority ratings at the time. Consequently, in 1967 the Medical School {MS} decided to embark independently on the project. The specific objectives o f the project were: i. To investigate the state o f the rural community, its social organisations, the factors that make for an effective participation in health problems and programmes and to undertake research into the most useful and efficient way o f utilising the services o f available manpower. ii. To train doctors, health centre superintendents, assistant sanitarians, all grades o f nurses, and other health workers specifically for their role in rural health work. iii. To provide both during training and afterwards manpower confidently oriented and equipped to handle the problems o f the community. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 41 iv. To provide through the Danfa Health Centre Comprehensive health care and preventive health services emphasizing maternal and child health services, nutrition, health education, communicable disease control; improved environmental health and Family Planning services. Barely two years after the founding o f a Medical School in Ghana {1964} it was decided that a community health project sited in a rural area would be a useful adjunct to the teaching hospital in the effort to acquaint the new doctor with community health problems. The responsibility o f organising such a rural health training was assigned to the Department o f Preventive and Social Medicine o f the Medical School. Such a decision might have been taken with much consideration o f the records on the importance o f a rural health training centre in the teaching o f community health in Africa Medical Schools {Bennet, Saxton and Lutwama, 1965, Namboze 1966}. The concept had received expression in several medical schools in Africa. The Ibarapa Project o f the University o f Ibadan Medical School, the Kasangati Health Centre o f Makerere Medical School, the Machakos rural Health Training scheme o f the Medical Faculty o f the University o f Nairobi and the Kibaha Training Centre o f the Department o f Preventive and Social M edicine o f the University o f Dar-es-salaam are notable ones. In the organisation o f any one o f these projects the integrated approach has been followed. That is, the use o f medical auxiliaries to provide health care to a rural community emphasing maternal and child health, health education, nutrition, environmental sanitation, immunization and communicable disease control. It was believed from the start that the success o f the project would depend to a large extent on the willing paticipation o f the local community. Accordingly in selecting the community some criteria had to be followed. Since the medical students’ participation in the project activities was one o f the major considerations, it was felt that the selected community should be near enough and accessible to the Medical School. At the same time it was felt that the chosen community should have characteristically rural features. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 42 In this regard, the lack o f safe water supply, electricity, secondary schools, good roads and the tendency o f the young people in the villages to move to the urban centres were considered typical rural features. The presence o f a common bondage and kingship among the various villages o f the chosen community was considered an essential ingredient o f future community organisation. In addition to common cultural and bonds, evidence o f already existing village A 1 groups as well as self-help projects supported by various government agencies were looked upon as favourable A for the survival o f such a project. After a meeting on the 29th o f March, 1967 which was adressed by the Professor o f the Department o f Preventive and Medicine, Danfa was selected as the headquarters o f the project. The active participation o f the project community was considered crucial to the success o f the programme {Wurapa 1973}. Consequently the earliest consultations with the community leaders was aimed at determining their felt needs. It became clear that a hospital, water, good roads, latrines, improved farming methods, schools and a better transport system were the priorities o f the community. W urapa mentions that although the order o f the list o f priorities o f the programme organizers was different from that o f the community, the construction o f the clinic was made the focus o f the activities (Wurapa 1973, 4). The strategy was that having gained the co-operation o f the community through the provision o f the clinic, it might be more feasible to get greater support for some o f the preventive and health promotive activities. What the planners failed to foresee was how to get the community involved in a project they could not see its importance. No doubt these problems later cropped up. Sai et al {1972} mention three significant problems that had to be encountered during the initial stages o f building the centre. 1. Soon after work had started, the villages reported that they could not provide the skilled labour because those they got could not be persuaded to work for the token wages they were going to be paid during the life o f the building programme. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 43 2. Work was disrupted by farm work and funerals. W henever it rained the villagers went to their farms and failed to honour their turn for communal labour. 3. Another problem o f serious consequence was the delay o f the villages o f Amrahia and Amanfro in joining in the construction o f the clinic. They had indicated earlier that their problem o f highest priority was availability o f good water and not a "hospital", because they could easily travel to a hospital by public transportation. It took about 9 months to persuade them to participate in the construction o f the clinic. Added to the above is the case where some o f the villages (5) in the project area had petitioned the government to close down a police post in one o f the villages {Ayimensah} and turn it into a "hospital" because as was reported "they were peace loving people and therefore had no need for a police post" (Sai 1973, 15). Despite the problems, the Danfa comprehensive Rural Health and Family Planning Project took o ff on January 16, 1970 with the important aim o f developing effective, high quality and affordable primary health care in the rural areas. As a joint-project between the Ghana Medical School and the school o f Public Health, University o f California, Los Angeles, it was essentially a demonstration, teaching, and research oriented venture. A series o f health ralated activities were to be undertaken later. In 1974, perhaps in an attempt to exploit the medicinal potentials o f the country's flora and also to tap the knowl