Adapting the health system in Ghana to reach the urban poor

在农村地区，加纳有一个完善的方案，由社区护士、社区卫生官员和志愿人员与农村社区合作，改善妇幼保健。这种方法被称为社区卫生规划和服务（CHPS），在农村地区进行的评估表明，这种方法使所有孕产妇死亡人数减少了一半，随着计划生育的普及，每名妇女所生的孩子数量减少了一个。这种做法虽然在农村地区取得了成功，但尚未推广到城市地区。加纳正在快速城市化，贫富之间的不平等程度高得令人无法接受，城市贫困社区14岁以下儿童的死亡率是一般城市人口的5倍。将卫生保健服务扩展到贫困的城市社区现在是政府的首要任务。这一建议是由加纳卫生服务机构（GHS）和国家CHPS规划内的卫生系统研究人员和决策者共同提出的。我们的目标是开展扩大CHPS所需的基础工作，使最贫困、边缘化的城市居民能够从这种方法中受益。我们将与三个城市社区密切合作，每个社区都有不同形式的城市贫困，例如非正式住区或更为混合的成熟社区。我们的团队包括GHS高级工作人员，包括卫生防护中心主任、护理研究主任和一支强大的卫生系统研究人员队伍。在整个GHS中工作过的加纳公共卫生登记员具有研究方法方面的专门知识，他们将与英国公共卫生登记员一起工作（该项目没有工资成本）。他们将在这三个领域分别进行两个焦点小组讨论。与会者将包括在获得保健服务方面面临各种挑战的育有子女的妇女。我们将进行大约。与边缘化群体和社区领袖进行了24次访谈。登记员将对城市社区卫生倡议进行案头审查。我们会收集现时在这三个地区所提供的服务的详情及收费。来自卫生防护系统规划和全球安全系统内部的关键决策者将聚在一起参加一个研讨会，设计一个城市卫生防护系统模型的原型，并确定需要开发的所有材料、指导方针和培训。我们的团队将开发实用工具，并根据整个项目的学习情况对其进行修改。卫生防护中心的工作人员和志愿者将接受培训，以提供新的模式，并将开始在三个地区实施。我们的团队将与卫生防护中心的工作人员和每个地区的社区成员一起促进参与行动研究小组。这些小组将确定问题，商定并实施解决方案，然后观察结果。这将导致学习和发展的持续循环。注册商将记录这一过程，收集成本和服务数据，以估计成本和提高利用率，并与边缘化群体进行定性数据，以告知改进措施。这将提供宝贵的新知识，说明如何让社区参与并发展城市卫生系统，以惠及最弱势群体。我们将借鉴一个理论框架，阐明社区参与中需要考虑的不同组成部分。这将确保我们开发的模式考虑到创建一个成功和可持续的社区参与模式的各个方面。我们的研究结果还将使我们能够对目前基于高收入国家证据的框架提出修改建议。与卫生服务中心和卫生服务中心决策者举行的最后一次研讨会将有助于详细制定一项计划，在加纳城市推广该模式。这也将使我们能够计划未来的大规模评估。到项目结束时，将提供一整套政策和实践文件，以便在整个城市地区进行推广。我们会为市区卫生防护中心设立卓越中心，以维持研究文化，不断评估和改善市区卫生防护中心的规模。

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.