Community-based Health Planning Services as a Primary Health Care strategy in Ghana.pptx

CHPS (Community-based Health Planning and Services) is considered one of the pragmatic strategies for achieving universal health coverage of a basic package of essential primary health services. CHPS is led by a Community Health Officer and supported by volunteers drawn from the area of service. CHPS strategy is a breakthrough in enhancing community involvement and ownership of primary health care interventions towards achieving Universal Health Coverage.
CHPS is designed to improve healthcare access, bridge equity gaps in accessing quality health services, and remove nonfinancial constraints to healthcare delivery. CHPS is the operational outcome of the Ghana Health Service’ “Close-to-client” system of primary healthcare delivery
Unlike the typical facility-based healthcare delivery, CHPS is a community-based, community-involved care system that enables District Health Management Teams to adapt and develop approaches to community healthcare that are consistent with local traditions, sustainable with available resources, and compatible with prevailing needs.

1. COLLEGE OF HEALTH, YAMFO DEPARTMENT OF COMMUNITY MENTAL HEALTH COURSE CODE SCMH 217: PRIMARY HEALTH CARE, PHC Bless Hayford Addo, MPH, MLS ( ASCPi ), BSc. Actuarial Science

2. CHPS as a PHC strategy in Ghana CHPS: Community-based Health Planning and Services Considered as one of the pragmatic strategies for achieving universal health coverage of a basic package of essential primary health services CHPS is led by a Community Health Officer and supported by volunteers drawn from the area of service CHPS strategy is a breakthrough in enhancing community involvement and ownership of primary health care interventions towards achieving UHC

3. Concept and Understanding of CHPS CHPS is a system designed to improve health care access to bridge equity gaps in accessing quality health services and to remove nonfinancial constraints to health care delivery CHPS is the operational outcome of the GHS’ “Close-to-client” system of primary health care delivery Unlike the typical facility-based health care delivery, CHPS is a community-based, community-involved care system that enables DHMT’s to adapt and develop approaches to community health care that are consistent with local traditions, sustainable with available resources, and that is compatible with prevailing needs

4. Background to CHPS CHPS began as a Community Health and Family Planning (CHFP) project based on lessons learned from Bangladesh (Phillips, 1988) The project was launched in Navrongo as an operations research in 1994 as piloted in three sub-districts Four different models of delivering community services were experimented to treat malaria, acute respiratory infections, diarrhoeal disease and other childhood illness and providing family planning services and immunization outreach Each experiment location was referred to as a Cell with different configurations of organisation of services

5. Background to CHPS

6. Background to CHPS The option that proved most successful was Cell 3 which had three components a compound where the CHNs lived and could be reached in emergency and a courtyard for delivering ANC and services when required volunteer assisted outreach program that encouraged case tracing and referral, health education and confidential counselling and and the Community Health Management Committees who oversee community mobilisation and participation, service delivery and welfare of both the Community Health Nurse and the Volunteers

7. Background to CHPS Medical Assistants from the Health Centre provided support for community entry and establishment, supervisory support and held zonal meetings to provide feedback on implementation Child mortality was reduced by 38% and total fertility was reduced by one birth (Pence et al., 2001) Case load increased eightfold, immunization and family planning coverage improved and fertility and mortality rates declined ( Debpuur et al., 2002) Key pilot districts included Nkwanta, Birim North and AburaAsebu-Kwamankese

8. Background to CHPS In 1999, consensus was reached to adopt and scale up the Cell 3 model as a national strategy to improve access, efficiency and quality of health care (Ghana Health Services, 2003) Fifteen steps were developed to guide the implementation process Community Health Nurses were provided further training and designated Community Health Officers (CHOs) as resident health care providers in a CHPS zone Zones were geographical coverage areas for community services

9. Background to CHPS The CHOs would provide reproductive, maternal and child health services, manage diarrhoea , treat malaria, acute respiratory infections and childhood illness and provide comprehensive family planning and childhood immunization outreach The CHOs were supported by volunteers whose roles involved educating the community on basic health issues and serving mainly as agents of referral services and community social mobilization (home visits by volunteers, treatment by CHO ) The model relied on communities and other stakeholders to provide financial or in-kind resources for construction and provide oversight for service delivery and welfare of the CHOs

10. Scaling up In 2000 work began on scaling up the CHPS concept Concerns about financial and geographical barriers to access to care NHIS was seen as the social intervention to address the financial challenge and CHPS was to make basic services available "close to the client“ In line with the expected rollout of the CHPS strategy, every CHPS zone was to have a CHPS compound comprising CHO accommodation and a service delivery point Patients who could not be handled at this level were referred to a Health Centre, district hospital and regional hospital in that order of upward referral Revised CHPS Compound design in 2012 (used to be 1 room for the CHO and 1 room for consultation; revised to 2 bedrooms with living room, kitchen, toilet and washroom facilities & a single room for consultation with a courtyard)

11. Scaling up Different designs and standards of developing CHPS (sizes vary from simple two-room structures to complex facilities as the size of some health centers) Varying specifications make it difficult to equip, maintain and manage these facilities In 2008 a new terminology "functional" was defined and added to the demarcation of CHPS zones The geographical demarcation for a CHPS zone was changed in 2010 from size of population or Unit Committees to be conterminous with electoral areas

12. Community-based Health Planning & Services CHPS is defined as a national mechanism to deliver essential community-based health services involving planning and service delivery with the communities CHPS was intended to create a more cost-effective vehicle for primary care delivery” CHPS is a strategy adopted by the MOH as a national programme to bridge the gap in healthcare access the community-based level service provision will enable the GHS to reduce health inequalities and promote equity of health outcomes by removing geographic barriers to health care ( communities in deprived subdistricts) A key component of CHPS is a community-based service delivery point that focuses on improved partnership with households, community leaders and social groups – addressing the demand side of service provision and recognizing the fact that households are the primary producers of health

13. Three-tier level of service provision The strategic policy of the GHS is to have a three-tier level of service provision within a district – the District (Hospital) Level, the Sub-District (Health Centre) Level and the Community-based level All Sub-districts are to be divided into zones with a catchment population of 3000 to 4500 where primary health care services will be provided to the population by a resident Community Health Officer (CHO) assisted by the community structures and volunteer systems The deployment of all elements necessary for the CHO to provide house-to-house service shall make that zone a fully functional CHPS zone within the sub-district

14. Three-tier level of service provision Each sub-district is demarcated into CHPS zones comprising up to 3 or 4 unit committees

15. The CHPS Activity Sequence Fifteen step-by-step activity sequences are provided as a guideline for implementation based on the Navrongo Experiment Refer to supplementary learning material number 4 (SLM 4) Based on the 15 CHPS activity sequence, six general implementation activities changed PHC services from a sub-district clinic-based operation to a comprehensive community-based programme Each of the specific elements is referred to as a “CHPS milestone” They include: 1. Planning

16. The CHPS Activity Sequence 2. Community entry 3. Community health compound (CHC) 4. Community health officer (CHO) 5. Essential equipment 6. volunteers

17. CHPS Milestone Planning “CHPS zones,” geographical areas where services are to be delivered, are mapped district-wide, dialogue with communities about their health needs is held, and a situation analysis of the existing health services within a district is conducted Community Entry: Activities with chiefs and leaders residing within a CHPS zone are conducted in order to introduce and gain acceptance for the process, a durbar to introduce CHPS to the entire community is held, and a Community Health Committee, responsible for community-level and volunteer components of the CHPS process, is selected and trained

18. CHPS Milestone Community Health Compound (CHC): the site where the CHO will live and provide services Phase includes securing funds for building or renovating a structure to serve as the CHC, selecting a site for the CHC that is acceptable and easily accessible to the entire community, and mobilizing communal labour for CHC construction Community Health Officer (CHO): title given to a certified community health nurse who has received additional training in order to provide the full complement of CHPS services Phase includes the training and deploying of the nurse to the CHPS zone and holding a durbar to introduce the CHO to the CHPS zone residents

19. CHPS Milestone Essential Equipment: In this phase, equipment essential for conducting CHPS services is procured This includes a motorbike for CHO community and home visitation and purchasing bicycles for health volunteers as well as essential service delivery equipment such as weighing scales, BP apparatus, thermometer etc. Volunteers : These are community residents who will aid the CHO by conducting health promotion activities and providing basic services This phase consists of selecting and training the community health volunteers, convening a durbar to introduce them, holding training for the Community Health Committee to oversee the work of volunteers and the procurement and distribution of their supplies, and training the CHO on how to work with health committees and volunteers The training sessions for each group of workers usually combine all the components described above

20. Components of CHPS implementation CHPS Zone refers to a demarcated geographical area of a 4-kilometer radius and between 4500-5000 persons or 750 households in densely populated areas and may be conterminous with electoral areas where feasible CHPS Community is a town, part of a town or a group of villages or settlements grouped together and designated as such by the district assembly as sub-units of a CHPS Zone. These are mapped for ease of planning of itinerant services and assignment of CHOs and CHVs. A CHPS Community in a densely populated area shall be approximately 1500 persons or 250 households

21. Components of CHPS implementation C. CHPS Compound refers to an approved structure consisting of a service delivery point and accommodation complex both of which must be present D. Community Health Officer (CHO) is a trained and oriented Community Health Nurse working in a CHPS zone and may be assigned to a Community within the zone E. Community Health Volunteers (CHVs) are non-salaried community members identified and trained persons supporting CHOs in a Community within the CHPS zone

22. Components of CHPS implementation F. Community Health Management Committees are community leaders drawn from the CHPS Community with different competencies and responsibilities who volunteer to provide community-level guidance and mobilisation for the planning and delivery of health activities and see to the welfare of CHOs in their community

23. General principles The general principles guiding the development and implementation of CHPS are Community participation, empowerment, ownership and volunteerism Focus on community health needs to determine the package of CHPS services Task shifting to achieve universal access Communities as social and human capital for health system development and delivery Health services delivered using a systems approach

24. Policy Directives The five policy directives to be applied and guide the implementation of this National CHPS Policy are Policy directive 1: Duty of care and minimum package of services Policy directive 2: Human resources for CHPS Policy directive 3: Infrastructure and equipment for CHPS Policy directive 4: Financing Policy directive 5: Supervision, monitoring and evaluation

25. Duty of care and minimum package of services Package will include: Maternal and reproductive health (emphasizing FP, ANC+, providing relevant information and motivating pregnant women to seek appropriate services including PMTCT and ANC, and to deliver under trained health worker supervision) and ASRH) Child Health services (EPI, nutrition education and support and Growth monitoring and promotion, Community Integrated Management of Childhood Illnesses) Treatment of minor ailments, including fever control, first aid for cuts, burns and domestic accidents, and referrals Health education, sanitation and counselling on healthy lifestyles and good nutrition Follow up on defaulters and discharged patients

26. Duty of care and minimum package of services Information and Surveillance: CHOs will keep records and report regularly according to standard protocols. The reports will include vital events in the CHPS zone and prompt notification of strange diseases or deaths and increased occurrence of known diseases such as diarrhoea , neglected tropical diseases and jaundice Deliveries may not be performed by CHOs They are expected to refer all delivery cases to a higher level of care. Based on need, the District Director of Health Services may include midwifery services in the package of services for a specific CHPS zone and post a qualified resident midwife to the zone

27. Duty of care and minimum package of services Where there is already a competent midwife operating in an accredited private maternity home within the zone, such a facility shall be the referral point for the CHPS zone Any earmarked or project services to be implemented at the community level and directly financed by any persons, institutions or development partners should be implemented on the CHPS platform

28. Human resources for CHPS CHN is a professionally classified cadre by the Nurses and Midwives Council for persons qualified and issued with the recognized specific license A CHN who undergoes the prescribed in-service training and orientation and is posted as a staff in a CHPS zone is designated as a CHO There shall be at least three (3) CHOs to a CHPS zone Each CHPS Community shall have at least two volunteers selected by the community and trained by the sub-district health team

29. Infrastructure and equipment for CHPS A CHPS compound is a basic structure consisting of accommodation for CHOs and a service delivery point which may also be referred to as a health post All CHPS compounds shall be standardized across the country using approved design options A CHPS compound shall be equipped and furnished

30. Financing Government shall allocate dedicated resources for the scaled up operations of the CHPS All services delivered in CHPS compounds shall be delivered free of charge at the point of use All CHPS services on the NHIS benefit package shall be reimbursed CHOs and their volunteers will facilitate the registration of their populations onto the NHIS

31. Supervision, monitoring and evaluation The District Director of Health Services being the technical lead in the District and reporting to the District Chief Executive and the district assembly shall have overall responsibility for guiding service delivery in the CHPS zones in the district Direct supervision of CHOs shall be the responsibility of the Officer in charge of the health centre in the sub-district

32. Community Engagement Sustaining CHPS operations continuously over time requires continuous community engagement, dialogue, and diplomacy to be pursued by DHMT, SDHT, District Assembly, stakeholders, and other partners STEPS : Community entry Community consultation Community needs assessment Community mobilization Community Decision Systems (CDS) Community Health Action Plan (CHAP)

33. Community entry Community entry is the process of combining principles and techniques to mobilise communities and get them to participate in and take ownership of health care delivery activities It is the first step in community engagement, and involves recognising the community leaders, structure, people and applying appropriate strategies in interacting with them Community Entry Process Form a community entry team Learn about the community Identify contact persons

34. Community entry Community Entry Process cont. Meet with the community’s leadership − Let community leaders and people know you and your mission in the community − Seek approval and support for CHPS’s activities and become conversant with the customs and traditions of the people Conduct meetings with the community Conduct community needs assessment

35. Community consultation Community Consultation Process Identify the leadership and recognize their positions and roles Meet them upfront to let them understand your message, purpose, mission, and vision Organize several meetings to convey message Work with them to organize community durbars to present your message to the wider community Follow the community protocols

36. Community consultation Key areas for consensus-building in CHPS Formation of CHMCs Operation of CHV system—selection of volunteers and their supervision Construction/Maintenance of CHPS compounds Safety and security of the CHPS compound and health workers Organization of communal labour Fund raising to support CHPS activities Identifying and using other community structures—opinion leaders, youth groups, etc.—to facilitate the CHPS programme activities

37. Community needs assessment Community needs assessment is a process of finding out and prioritising the local problems of a community, identifying the environmental and socio-cultural factors influencing such problems, and discovering resources available in the community to solve the problems It establishes the essential foundation for vital planning, and identifies the strengths and resources available in the community to meet the needs of children, youth, and families

38. Community needs assessment Community Needs Assessment Process Collect information and organize discussions on health needs with community members Discuss and analyze community health issues with community members, SDHT, and other health workers Hold meetings with chiefs, leaders, and social groups, e.g. Mothers club Use information to develop CHAPs with community members Implement CHAPs and evaluate

39. Community mobilization Community mobilization is a process by which communities are motivated to bring together human, material, or financial resources to take action to improve their state of development and well-being It involves activities that are planned, carried out, evaluated by community members or with the support of others in a participatory manner, and sustained to achieve the community’s developmental goals

40. Community mobilization Steps in Community Mobilization Identify stakeholders Meet with stakeholders to discuss health issues Identify resource strength of each stakeholder Share roles and responsibilities for all stakeholders Develop a community mobilization plan which includes agreed-upon contributions from stakeholders with timelines Follow up on the pledged resources from stakeholders Mobilize all resource

41. Community Decision Systems (CDS) In CDS, community members gather and use information about their health problems to facilitate decision making, planning interventions, acting together, and monitoring to improve their own health situations Key Players in CDS include all members of the community; CHMC; other community health providers e.g. herbalists, TBAs, chemists, Wanzams (circumcisers); an Okyeame/Linguist or MC; CHVs & CHOs

42. Community Decision Systems (CDS) CDS Process Design community bulletin board/screen/wall Design pictorial indicator cards (cards on health issues) Formation of Community Health Team Data collection by the Community Health Team Organize community durbar to return information to the community Present the information in a clearly understandable form (numbers, percentages, etc., using the cards)

43. Community Decision Systems (CDS) CDS Process cont. Facilitate discussions and analysis of information Use the information to make decisions and take action Prepare CHAPs Implement planned activities Monitor, supervise and evaluate the action plan

44. Community Health Action Plan (CHAP) CHAP is developed by community members with GHS staff such as CHO, SDHT, and DHMT providing the necessary support CHAP is implemented by community members It is reviewed and updated on a regular basis by community members and the CHO to make room for new activities after the achievement of current targets on the plan The rationale for CHAP is to promote community involvement, develop ownership, and help set a vision for the CHPS zone. It serves as a monitoring and evaluation tool for the CHPS implementation and can attract donors and philanthropists to the community

45. Community Health Action Plan (CHAP) CHAP Implementation Action Plan Assess needs of community using PLA tools Hold meetings to sensitize communities on CHAP Hold a series of durbars involving all the community members When communities embrace the CDS ideas and findings, enumerate challenging issues and prioritize them for CHAP Community draws CHAP facilitated by health worker/CHO and an active community member Display CHAP on local wall for reference by all members involved in its implementation Health worker/CHO/CHMC/CHVs to follow up with persons responsible for activities specifies

46. Conducting a Situation Analysis This is the process by which the DHMT carries out a critical examination of its operations in the delivery of PHC services to the people of the district with the view of: Assessing its capabilities Identifying the challenges Developing a new and more relevant program of action Areas assessed in conducting the situational analysis include: Service Coverage (Sub-districts and the main communities, existing service delivery points, and types of services offered) with respect to coverage & patronage ( better or poor and why?)

47. Conducting a Situation Analysis Resource status (status of facility & sources of funding) CHNs and level of work (Number of public health nurses in the district; number of CHNs in the district; number of CHNs in the sub-district; number of patients seen by the CHNs at each of the identified service points in a month; nurse-patient ratio i.e. average number of patients seen by each CHN is a week, a month etc.) Output of the Situation Analysis Draft District Health Service Profile (DHSP): reveal the merits and inadequacies in PHC delivery in the district as well as the sub-districts Draft Health Action Plan (HAP) for implementing CHPS

48. Community Profile Refer to SLM 4

49. Continuous Delivery of Services Refer to SLM 4

50. Referral systems Refer to SLM 4