Research projects demonstrating ways to improve health services often fail to have an impact on what national health programmes actually do. An approach to evidence-based policy development has been launched in Ghana which bridges the gap between research and programme implementation. After nearly two decades of national debate and investigation into appropriate strategies for service delivery at the periphery, the Community-based Health Planning and Services (CHPS) Initiative has employed strategies tested in the successful Navrongo experiment to guide national health reforms that mobilize volunteerism, resources and cultural institutions for supporting community-based primary health care. Over a 2-year period, 104 out of the 110 districts in Ghana started CHPS. This paper reviews the development of the CHPS initiative, describes the processes of implementation and relates the initiative to the principles of scaling up organizational change which it embraces. Evidence from the national monitoring and evaluation programme provides insights into CHPS' success and identifies constraints on future progress.

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BackgroundDuring the 1990s, researchers at the Navrongo Health Research Centre in northern Ghana developed a highly successful community health program. The keystone of the Navrongo approach was the deployment of nurses termed community health officers to village locations. A trial showed that, compared to areas relying on existing services alone, the approach reduced child mortality by half, maternal mortality by 40%, and fertility by nearly a birth — from a total fertility rate of 5.5 in only five years. In 2000, the government of Ghana launched a national program called Community-based Health Planning and Services (CHPS) to scale up the Navrongo model. However, CHPS scale-up has been slow in districts located outside of the Upper East Region, where the “Navrongo Experiment” was first carried out. This paper describes the Ghana Essential Health Intervention Project (GEHIP), a plausibility trial of strategies for strengthening CHPS, especially in the areas of maternal and newborn health, and generating the political will to scale up the program with strategies that are faithful to the original design.Description of the interventionGEHIP improves the CHPS model by 1) extending the range and quality of services for newborns; 2) training community volunteers to conduct the World Health Organization service regimen known as integrated management of childhood illness (IMCI); 3) simplifying the collection of health management information and ensuring its use for decision making; 4) enabling community health nurses to manage emergencies, particularly obstetric complications and refer cases without delay; 5) adding $0.85 per capita annually to district budgets and marshalling grassroots political commitment to financing CHPS implementation; and 6) strengthening CHPS leadership at all levels of the system.Evaluation designGEHIP impact is assessed by conducting baseline and endline survey research and computing the Heckman “difference in difference” test for under-5 mortality in three intervention districts relative to four comparison districts for core indicators of health status and survival rates. To elucidate results, hierarchical child survival hazard models will be estimated that incorporate measures of health system strength as survival determinants, adjusting for the potentially confounding effects of parental and household characteristics. Qualitative systems appraisal procedures will be used to monitor and explain GEHIP implementation innovations, constraints, and progress.DiscussionBy demonstrating practical means of strengthening a real-world health system while monitoring costs and assessing maternal and child survival impact, GEHIP is expected to contribute to national health policy, planning, and resource allocation that will be needed to accelerate progress with the Millennium Development Goals.

The original CHPS model deployed nurses to the community and engaged local leaders, reducing child mortality and fertility substantially. Key scaling-up lessons: (1) place nurses in home districts but not home villages, (2) adapt uniquely to each district, (3) mobilize local resources, (4) develop a shared project vision, and (5) conduct “exchanges” so that staff who are initiating operations can observe the model working in another setting, pilot the approach locally, and expand based on lessons learned.

This paper reports key findings and conclusions from a 1996 study of user fees and exemptions in the Volta Region of Ghana. A variety of data sources and methods were used, including interviews with patients and managers, community-based focus group discussions, analysis of facility records and analyses of previous household survey data. Official fee levels and exemption categories were established in 1985. While this legislation made provision for drug fees to be 'at cost' and thus to be revised in line with inflation, other official fees have not been adjusted since 1985. In the face of declining real levels of budget allocations and decreased supplies of essential consumables from the Central medical stores, facility managers have established their own pricing and fee collection systems. This has been allowed by the Ministry of Health, but the decentralized nature of fee setting and collection practices has made it very difficult for the Ministry to monitor the effects of fees. The study found that facility managers have been very active in setting and collecting fees and using the revenues to purchase essential inputs. The level of revenues being mobilized accounts for between two-thirds and four-fifths of the non-salary operating budget of government health facilities, and virtually all of the resources for non-salary operating expenses in mission hospitals. Official exemptions are largely non-functional. Less than one in 1000 patient contacts were granted exemption in 1995. With estimates that between 15 and 30% of the population lives in poverty, the failure of exemptions to function means that fees are preventing access for the poor, or are imposing significant financial hardships on this part of the population. Health facilities in the Volta Region have achieved a kind of 'sustainable inequity', with fees enabling service provision to continue, while concurrently preventing part of the population from using these services.