Adapting the health system in Ghana to reach the urban poor

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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.