GEHIP’s Community-based Primary Healthcare Program
As part of efforts to improve access to healthcare in remote rural communities, Ghana’s Ministry of Health supported the design and feasibility testing of community-based healthcare program in a rural district in northern Ghana between 1994-1996 , and a follow up plausibility trial from 1996 to 2003 . The results of these studies showed that community-based primary healthcare improves access to healthcare, leading to improvements in several maternal and child health indicators. In response to this evidence, the Ghana Health Service (GHS) launched the Community-based Health Planning and Services Program (CHPS) as a national policy in the year 1999 to scale up this successful initiative nationwide .
However, CHPS nationwide scale-up was constrained by challenges related to inadequate understanding of its service delivery modalities, communication deficits, low human resources capacity, lack of material logistics including funds and leadership bottlenecks . An in-depth review of the operational constraints to CHPS scale-up by the Ghana’s Ministry of Health in 2009 provided a set of needs that was used to inform the design of a project known as the Ghana Essential Health Interventions Program (GEHIP) to demonstrate practical means of implementing and scaling up community-based primary healthcare .
The GEHIP project was implemented in a poor remote region of Ghana; the Upper East Region (UER). This region is located within the Sahelian savannah ecological belt in the north-eastern part of Ghana. It has a population of about 1.3 million . It has a poverty prevalence of 55% and almost 40% of its indigens have no formal education . GEHIP project was implemented in seven districts in this region with three serving as intervention districts while four others serving as non-intervention comparison districts. Both intervention and comparison districts were purposively selected based on their remote geographic isolation and socioeconomic deprivation.
GEHIP interventions included training and technical assistance provided to district-level health managers and frontline community health workers. These trainings aimed at building their capacity in both community and stakeholder engagement to support health service delivery and utilization. The project focused on addressing the challenges of effectively marshalling the system associated with the management of existing staff, equipment, pharmaceutical supplies, and leadership capacity for primary healthcare. Focus was directed to improving the implementation of the WHO’s six health system building blocks . At the onset of the GEHIP, there was no shortage of nurses for expanding community-based healthcare operations in Ghana; but rather, a lack of health facilities in most communities/villages where trained nurses could be posted to render services . Also limited was district-level leadership understanding of strategies for obtaining resources for constructing and managing community health posts effectively .
To address these challenges, GEHIP developed a framework for strengthening community-based primary healthcare. The strategy was focused on improving district-level leadership capacity, use of information for decision-making, logistics, and budgeting, health worker training, and deployment for the provision of healthcare at the community locations. Specific maternal and child health interventions were included within GEHIP, including the integrated management of childhood illness regimen recommended by the WHO . GEHIP also developed a referral service program that enhanced health facility delivery using community engagement strategies to improve social support for referral operations . GEHIP was a plausibility trial in that the introduction of intervention was configured at the district level, preventing the imposition of randomized assignment of treatment observational units. Methods for statistical analysis of non-experimental conditions were therefore required . In the programmatic context of the Ghana Health Services (GHS), region-wide implementation of some interventions involving health worker training and deployment program focused on WHO recommendations for caring for the mother and newborn as well as the integrated management of childhood illness . All such national program interventions were implemented equivalently in treatment and comparison districts.
The main objective of this current study is to assess the effect of GEHIP’s community-based health program on adverse birth outcomes. To achieve this, we examine; 1) the proportion of adverse birth outcomes for both intervention and non-intervention districts and the average treatment effect of GEHIP on birth outcome, 2) assess the distribution of adverse birth outcomes by wealth index and mother’s educational attainment for both intervention and non-intervention districts and 3) examine the equity effect of GEHIP’s community-based healthcare program on birth outcomes by household wealth index and maternal education.