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Universal health coverage Community health workers delivering primary healthcare: opportunities and challenges

The Association of Community Health Nurses, Ghana has just concluded its annual conference at Bolgatanga the regional capital of the Upper East region. For such an important cadre of health workers to return to Upper East region, where it all begun is exciting and historic.

In Ghana, commitment to Community Health Workers (CHW) programming as a component of a national model to strengthen Primary Health Care (PHC) originated as a volunteer-based program. With the identification of systemic challenges, tailored interventions were adopted leveraging the potential of CHWs to strengthen the health system.

The Community-based Health Planning and Services (CHPS) program became the national primary health care policy of Ghana in the early 2000s demonstrating the impact of deploying community health nurses (CHOs) and mobilizing community leadership structures in the Upper East Region of Ghana.
This was later refined into a national program with a series of replication projects undertaken in each region of Ghana to clarify implementation milestones and refine strategies for spreading national scale-up of CHW deployment.

Since the establishment of CHPS, more than 6,000 CHWs have been deployed to communities across Ghana. Over the course of this scale up, however, the community health worker component waned. After nearly a decade of implementation, monitoring research of the Ghana Health Service showed that the pace of scale-up was unacceptably slow in some regions with less than one-third of the targeted population being reached.
Among the key concerns identified were that weak training and supervision affects the implementation of CHPS. Moreover, inadequate supplies, materials, operational funds and equipment coupled with lack of CHOs recognition have effect on the commitment and ownership of the CHPS strategy at the community level leading to the introduction of the Ghana Essential Health Intervention Programme (GEHIP) again in the Upper East region.

GEHIP sponsored a program of district leadership development and strengthening, resource mobilization with catalytic funding and community engagement that produced total CHW deployment reaching all target communities within four years. CHW deployment included three cadres: community health officers, community health volunteers and health extension workers.

With this, a comprehensive systems approach to CHW deployment was developed and implemented. In the process, it was determined that critical components to adequate scale-up of CHW programs necessitated comprehensive training and adequate compensation and political and community engagement.
Hence showing that integrating health systems strengthening as an embodiment of community health interventions yields the needed results at the primary health care level.
Ghanas CHPS program is resulting in a measurable improvement in health outcomes, and the national adoption of partnership interventions, including streamlined data collection, is useful and still underway.
A key lesson from these interventions is the importance of health systems designed to support the CHWs and their care delivery. If systems support is adequately rendered, and if strategies are sufficiently aligned with community needs and governance capabilities, CHW programs have a better chance to be sustainable and effective.
CHWs are a promising health workforce for accelerating progress in achieving Universal Health Coverage for enabling health systems in resource-constrained settings like Ghana. Addressing therefore the critical needs and concerns of CHWs is necessary for achieving our national UHC agenda.

Source: Dr. Koku Awoonor

The writer is the Director, Policy Planning Monitoring and Evaluation Division of the Ghana Health Service and former Regional Director of Health Service for the Upper East Region.

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