Adapting the health system in Ghana to reach the urban poor

In rural areas, Ghana has a well-established programme of community-based nurses, community health officers and volunteers working with rural communities to improve maternal and child health. The approach is called Community Health Planning and Services (CHPS) and evaluations in rural areas have shown that the approach has halved all maternal deaths and with increased access to family planning, reducing by one the number of children a woman gives birth to. While successful in rural areas, the approach has not yet been extended to urban areas. Ghana is urbanising rapidly and inequalities between the rich and poor are unacceptably high, with children under the age of 14 in poor urban communities five times more likely to die than the general urban population. Extending CHPS to poor urban communities is now a top government priority. This proposal has been put together by health systems researchers and policy makers embedded within Ghana's health services (GHS) and the national CHPS programme. Our aim is to conduct the foundation work needed to scale-up CHPS so that the poorest, marginalised urban residents can benefit from the approach. We will engage closely with three urban communities, each with different variations of urban poverty, for example informal settlements or more mixed, well-established neighbourhoods. Our team includes senior GHS staff, including the head of CHPS, head of nursing research and a strong team of health systems researchers. Ghanaian public health registrars who have worked throughout GHS, with expertise in research methods, will work alongside UK public health registrars (at no salary cost to the project). They will conduct two focus groups in each of the 3 areas. Participants will include women with children facing a variety of challenges to accessing health care. We will conduct approx. 24 interviews with marginalised groups and also community leaders. The registrars will conduct a desk review of urban community health initiatives. We will collect details of current services provided in the 3 areas and their costs. Key decision makers from within the CHPS programme and GHS will come together for a workshop to design a prototype urban CHPS model and identify all materials, guidelines and training that need to be developed. Our team will develop the practical tools and revise them based on learning throughout the project. CHPS staff and volunteers will be trained to deliver the new model and will begin implementation in the three areas. Our team will facilitate participatory action research groups with the CHPS staff, community members in each of the areas. The groups will identify issues, agree on and implement solutions and then observe the results. This will lead to a continual cycle of learning and development. The registrars will document this process, collect cost and service data to estimate cost and increase in utilisation and qualitative data with marginalised groups to inform improvement. This will provide valuable new knowledge on how to engage communities and develop an urban health system to reach the most vulnerable. We will draw on a theoretical framework that spells out different components to consider in community engagement. This will ensure that the model we develop considers all aspects of creating a successful and sustainable community engagement model. Our findings will also allow us to propose modifications to the framework which is currently based on evidence from high income countries. A final workshop with CHPS and CHS decision makers will enable the detailed development of a plan to scale-up the model across urban Ghana. It will also enable us to plan for future large scale evaluation. By the end of the project, a full suite of policy and practice documents will be available to enable scale-up across urban areas. We will establish a centre of excellence for Urban CHPS to maintain the culture of research to continually evaluate and improve urban CHPS as it is scaled up.

In rural Ghana the Community Health Planning and Services (CHPS) has been successfully implemented. Evaluations identify reductions in childhood mortality and fertility rates. Despite government policy to scale CHPS nationally, benefits do not extend to urban populations. Ghana is urbanising rapidly; inequities are unacceptably high. Few studies analyse potentially scale-able models in LMICs.
We aim to 1) adapt Ghana's CHPS to reach and engage the urban poor to effectively improve their health. 2) To understand social structures, health seeking and insurance behaviour and needs of urban poor 3) develop system-wide approaches addressing community engagement, access to insurance, human resource skills and service delivery for effective CHPS delivery.
In partnership with Ghana Health Service (GHS), we will select 3 urban areas of differing characteristics to implement a prototype urban CHPS model. In the 3 areas we will assess baseline service utilisation, conduct focus groups (6) and interviews (24) to understand social and health behaviours. We will conduct 20 interviews with CHPS staff and communities in the few existing urban CHPS pilots. Following workshops with government and communities, we will use participatory action research (PAR) with CHPS staff and communities to observe implementation of the redesigned CHPS model. Routine data will be analysed to assess utilisation and cost per utilisation compared to baseline and across the 3 areas. Further interviews (20) with marginalised households will be conducted. Interviews and focus groups will be audio-recorded and transcribed. Detailed notes will be taken during PAR. Data will be analysed thematically using Brunton's (2013) framework to understand engagement in the urban health system. Our team includes senior members of GHS including CHPS, ensuring future implementation and research. Development of policy, operational guidelines, training materials will further facilitate scale-up of the urban CHPS model.

In the long-term, our goal is to scale-up urban CHPS so that poor urban families, particularly women and children, have timely and appropriate access to the range of community level health promotion, prevention and basic clinical care primary services such as home visiting, education, vaccinations, and outpatients care for minor ailments delivered through the CHPS program.
i) Ghana Health Services and CHPS: For GHS and CHPS program this project will have lasting impact by providing details of all components and their costs necessary to deliver the national policy of scaling-up CHPS to cover all of Ghana prioritising the most deprived urban areas. Our focus on the most marginalised communities will maximise insights on how to reach these groups as CHPS is scaled up. The study will provide materials and training needed to adapt the program to unique urban contextual circumstances and increase the coverage of CHPS across poor urban communities. The urban health workforce will be strengthened with training provided to Community Health Officers (CHOs) and volunteers. The study will also facilitate a culture of operational research with the urban CHPS program providing potential for future research to ensure the continual improvement of CHPS and other interventions to improve the health and well-being of urban poor communities. Findings on the challenges faced by the urban poor in registering for health insurance or for the free insurance card provided for the extreme poor by the LEAP programme, will provide valuable information for further developments and policy directions in the National Health Insurance Authority.
ii) Urban poor: Within this initial foundation award, there will be direct beneficiaries in urban poor communities. Our project will work in three urban CHPS areas (zones) covering 5,000 - 10,000 marginalized urban households per zone. Evidence from rural CHPS shows basing CHOs within communities led to a reduction in childhood mortality by a third [11] and decline in the total fertility rate by one birth [12]. Promoting health amongst the poorest increases their chances of benefiting from the potential economic and social advancement that urban living can bring. This will benefit individuals, communities and ultimately the economic and social development of LMICs.
iii) Academics, urban health policy makers and practitioners globally: Urban health decision-makers and academics are struggling with the challenges of responding to the changing and expanding health needs of their growing populations. While many countries have community health workers and volunteers in rural areas (e.g. Lady Family Health Workers in Pakistan or Female Community Health Volunteers in Nepal), few cities have functional government-funded systems of community health workers and volunteers in urban areas. Our study will provide much needed knowledge on 'how to' adapt the health system to reach poor urban communities. Given the challenges facing urban municipalities and governments across LMICs, addressing this gap in the knowledge base is timely and important.
iv) Public health registrars in Ghana and UK: a novel component of this proposal the plan to 'twin' public health registrars from the UK and Ghana. This approach has the potential to impact on the future public health workforce in both countries. The UK's public health training programme has a long history of providing highly competent individuals to work not only in the UK's public health system but also for multi-laterals such as WHO and UN agencies as well as DFID. Such increased understanding of global health also improves cultural competence and the way that global health issues are dealt with within the NHS and Public Health England.