Background
Methods
Study setting and participants
Recruitment of study participants
Characteristics | Community FGDs | |||
---|---|---|---|---|
Avedo (N1) | Agoufie (N2) | Mbanayilli (N3) | Galwei (N4) | |
Avg. ages in groups | ||||
Mothers | 25.7 | 33.4 | 33.5 | 29.6 |
Fathers | 33.2 | 35.8 | 35.9 | 26.6 |
Young Boys | 16.8 | 16.0 | 17.6 | 18.7 |
Young Girls | 20.7 | 17.3 | 18.8 | 17.6 |
Community Leaders | 62.2 | 63.6 | 61.6 | 52.9 |
% with secondary and above education in groups | ||||
Mothers | 77.8 | 8.3 | 25.0 | 0.0 |
Fathers | 71.4 | 33.3 | 0.0 | 62.5 |
Young Boys | 100.0 | 50.0 | 87.5 | 100.0 |
Young Girls | 87.5 | 33.3 | 100.0 | 100.0 |
Community Leaders | 40.0 | 7.7 | 0.0 | 28.6 |
% religious affiliation | ||||
Christian | 81.1 | 39.5 | 0.0 | 0.0 |
Moslem | 0.0 | 7.0 | 100.0 | 91.9 |
Traditional | 13.9 | 27.9 | 0.0 | 0.0 |
No religion | 0.0 | 25.5 | 0.0 | 8.1 |
Data analysis
Results
Rating of CHPS by participants
Participant group: | Mean Score | Frequency | Score: | ||
---|---|---|---|---|---|
Standard Deviation | Minimum | Maximum | |||
Adolescents | |||||
Adolescent boys | 6.56 | 27 | 3.09 | 1 | 10 |
Adolescent girls | 7.13 | 24 | 2.11 | 4 | 10 |
Adults | |||||
Mothers | 9.20 | 26 | 1.20 | 6 | 10 |
Fathers | 6.86 | 28 | 2.50 | 1 | 10 |
Leaders | 8.83 | 21 | 1.38 | 5 | 10 |
Traditional, other | |||||
Communities: | |||||
• Avedo | 6.08 | 36 | 2.54 | 1 | 10 |
• Agoufie | 9.22 | 18 | 1.26 | 5 | 10 |
• Mbanayille | 8.58 | 36 | 1.26 | 6 | 10 |
• Galwei | 7.51 | 36 | 2.77 | 1 | 10 |
Average | 7.7 | 126 | 2.4 | 1 | 10 |
Positive attributions of CHPS
CHPS rating | Thematic areas | Participant justification for the scores: |
---|---|---|
10 | Appreciation |
I will rate it 10 because they are doing well.
|
9 | Missing key service |
I will rate it 9 because they do not carry out blood transfusion
|
7 |
I will rate it 7 because they do not treat all the sicknesses we take there.
| |
8 | Can still do better |
I will rate their services 8 because there is still a lot that needs to be done.
|
10 | Confidence |
I will rate it 10 because I believe in them.
|
10 | Appreciation |
The CHPS is doing well, but it needs a lot of improvement. Because referring us means they do not have enough machines, medicines and other health materials. I will rate it at 10 out of 10
|
10 | Hard work |
I would give them 20 out of 20 because they are working hard at the facility. When you go there at night and wake them up, they would attend to you. They would stay with the patient till daybreak. So I would give them all 20 out of 20.
|
10 | High efficiency |
I think 10 should have been added to the 20 to make it 30 because my wife gave birth at the facility twice and one time when we get to the facility the doctor told me if we had wasted another 5 min the child would have died and today the child is grown, so why won’t I praise God. I wish I had the strength, I would have expanded the facility.
|
Participant 5: The facility being in this community means a lot to us. At first, money to travel to a health facility was discouraging most of us from taking our sick children and relatives to the hospital. God has blessed us with doctors and nurses in the community and so we are grateful [Community members sometimes refer to CHPS staff as doctors and nurses] (N2 mothers of children below the age of five).Participant 1: It is an asset to be remembered, it is something for us in the future (N2 community leaders).Participant 2: It stands for our strength. (V1 fathers of children below the age of five)
Interviewer: Why have you rated them so?Participant 1: I rated them 5 because although they are doing well, there are some things they do not do or lack. For example, in the labor room a male nurse attends to you instead of a female nurse. The facility also requires beds and a room for blood transfusion which they don’t have.Participant 3: I rate them 5 out of 10 because they are unable to attend to all cases/ health problems sent to them … … … (N2 adolescent girls without children)
Participant 1: We have realized that pregnant women who go to CHPS for antenatal have easy delivery and their babies are in good health.Participant 2: To add to that, when a woman is pregnant and the doctors attend to her, they keep records of the person. My wife also had her baby there and it’s good. (fathers of children below the age of five)
P: I would give them 10 out of 10 because they are working hard at the facility. When you go there at night and wake them up, they would attend to you. They would stay with the patient till daybreak. So I would give them all 10 out of 10 … …. (N2 Mothers of children below the age of five)
Participant: I will rate their services 8 because there is still a lot that needs to be done.Participant: I will rate it 7 because they do not treat all the sicknesses we take there … … . (N2 Mothers of children below the age of five)
Interviewer: How would you rate CHPS services in your community? If you are to rate CHPS services in your community out of ten, how would you rate it.Participant 6: 10/10 because they deliver us safely and take good care of us and our children.Participant 4: 10/10 because no matter the time I come to the facility, they always attend to me and my family.Participant 3: I will rate them 10/10 because when I delivered, my breast was swollen, with their help, I was well again.Participant 1: 10/10 because the facility is always there for us (N1 Mothers of children below the age of five)
I will rate it 10 because I believe in them (N2 Mothers of children below the age of five)
Participant 3: I think 10 should have been added to the 10 to make it 20 because my wife gave birth at the facility twice and one time when we get to the facility the doctor told me if we had wasted another 5 min the child would have died and today the child is grown, so why won’t I praise God. I wish I had the strength, I would have expanded the facility … .. (N2 Community Leaders).Participant 4: The reason why I gave ten was that, when my grandmum fell sick they went to call them [health workers] and she did not hesitate to come with me. They took her BP [blood pressure] and looked for a vehicle for her to be taken to the main hospital …. (V1 adolescent girls without children).Participant 7: We never had a hospital here in the past and our roads were very bad. The CHPS that we have in this community is very good. If one is sick, no matter how late in the night and you are able to get to the nurse here, she will treat the patient. If you go to her and she can’t, she will try and send you to Nkwanta [The main referral centre in the district] using her own motorbike that was supplied by the government … .. (V2 Community Leaders)
Negative attributions of CHPS
CHPS scoring | Thematic Areas | Participant justification for the scores: |
---|---|---|
1 | Poor human relations |
Because they don’t have good human relations.
|
2 | Time & unavailability |
They are not always around.
|
5 | Extortion |
Sometimes they are helpful and sometimes too they take money from us and that’s bribe.
|
3 | Inefficiency |
They didn’t heal my sickness, I had to go to another place for treatment after visiting the CHC
|
2 | Weak follow up |
When we take our younger siblings to the hospital, 3 days after, they have to come and check up on them from our village but they don’t do it.
|
1 | Low capacity |
Because if someone is seriously sick and you take the person there and they are even taking care of another person, they have to excuse themselves and at least know what is wrong with the person before going back to the person they were working on earlier. They waste time and afterwards, refer you to another hospital when it is late in the evening.
|
Participant: Madam, for me the main hospital is better than what is here … …. (V1 adolescent girls without children)
Participant : I took my sister’s daughter to the clinic and they gave me some drugs but they took one cedis from me. That’s why I rated CHPS 5[US $ 0.20].Participant : If you don’t take health insurance to the clinic, they take one cedi from you (V1 adolescent girls without children)
Participant: Sometimes, by the time we get there the drugs are finished and they only provide us paracetamol tablets. Meanwhile what is happening to the baby or the child can’t be treated by paracetamol. Always there are no drugs until 1 month or two before they bring in some drugs. Sometimes when a pregnant woman goes there and they write prescriptions for her, she will have to travel all the way to Sogakope [a health facility about 30 km from the community] before getting some of the drugs (V1 Mothers of children below the age of five)
Participant 4: Nkwanta has nice drugs, we need some too here to prevent us from going to Nkwanta.
Participant 4: I rate them 4 but of 10 because they do not undertake caesarean sections.Participant 4: Everything, blood, infusions and ceasearn section, all [at] Nkwanta, why don’t we have some here? (V2 Mothers of children below the age of five).Participant 4 - The facility does not provide blood transfusion services that is why some people run to other places. (N1 adolescent boys without children)
Participant 6 : The condition of the patient can be out of the control of health personnel at the CHPS compound, so instead of being referred, we travel to other facilities (N1 adolescent boys without children)
Participant 6: Their opening time is very bad. They open around 8 am. If you get there as early as 5.30–6.00 am, nobody is there to attend to you. Sometimes 8.30 to 9.00 am before they open.Participant 4: Sometimes they don’t work during the weekend. But no one can tell when somebody will fall sick (V1 Fathers of children below the age of five).Participant : The last time I took my little sister to the clinic at 7:00 am, they attended to her around 8:00 am. At that time the sickness had worsened.Participant: I will rate CHPS 7, because there is no night services (V1 Fathers of children below the age of five)
Score | Biavariate results: | OLS regression results: | |||||
---|---|---|---|---|---|---|---|
Mean Age | Secondary schooling % | Coefficient | Robust Standard Error | t ratio | 95% confidence interval: | ||
Mothers | 30.55 | 27.78 | 2.74 | 1.31 |
2.09*
| .0025 | 5.48 |
Fathers | 32.86 | 41.80 | 0.11 | 1.69 | 0.07 | −3.43 | 3.66 |
Community leaders | 60.08 | 19.08 | 2.28 | 1.24 | 1.80 | −0.36 | 4.84 |
Adolescents | |||||||
girls | 18.60 | 80.20 | .529 | 1.26 | 0.42 | −2.11 | 3.17 |
boys | 17.28 | 84.38 | (reference) | ||||
Community: | |||||||
• Avedoa | 31.72 | 75.34 | (reference) | ||||
• Agoufieb | 33.22 | 26.52 | 3.40 | 1.01 |
3.38**
| 1.29 | 5.50 |
• Mbanayillic | 33.48 | 42.40 | 2.49 | 0.89 |
2.78**
| 0.62 | 4.36 |
• Galweid | 29.08 | 58.22 | 1.30 | 1.35 | 0.96 | −1.52 | 4.12 |
Constant: | 5.02 | 1.55 |
3.24**
| 1.78 | 8.27 | ||
Regression summary statistics: | |||||||
F (7,19): | = 4.41*** | R2 | =0.442 |
Expectation of CHPS by communities
Participant 5: We need a medical doctor here, if we had one here our nurse here would not transfer us again, if we get a surgeon to do the caesarean section for us. Also we need is a laboratory here.
Capabilities mandated by official policies: | Respondent perceptions of primary health care capabilities: | Examples of possible program responses: |
---|---|---|
General system capabilities:
| ||
Medical procedures that require specialists: Blood transfusion, surgery, caesarean sections, medical scans | Some discussants expect such services to be provided by CHPS | Expand community education about services that are appropriately provided at each level. |
Hospital personnel: Medical doctor available | Some respondents requested access to personnel with a higher skills than existing nurses | Develop and promote an affordable emergency referral system |
Staffing of sub-district clinics: Clinics have the full range of paramedical staff posted to facilities including medical assistants, midwives and registered nurses | More staff should be posted to Sub-district Health Centers. Most facilities have only two types of nurses and many lack medical assistants. | Conduct a total district systems appraisal: Review staffing policy, training norms, and implementation strategies at each level of the system. |
CHPS capabilities:
| ||
✓ ĴStaffing | ||
One midwife with one or two Community Health Officers in each service zone | CHPS facilities do not always have the full complement of CHOs. Many CHPS facilities lack midwives. | The Ghana Health Service is expanding midwife training and deployment. However, consideration of training CHO as interim birth attendants is warranted. |
✓ CHPS patient relations: | ||
• Prioritize patients coming from afar | First come first served | In-service training on client relations is urgently needed [12] |
• Patient oriented staff attitudes | Some discussants encountered rude and impersonal care | |
• Staff responsive to emergency situations | Discussants noted that CHPS care is not always available after office hours. | There is a need for time-use analysis and a revised policy statement on worker hours of access. |
✓ CHPS logistics: | ||
The facility has space to ensure privacy and reasonable comfort for its clientele | Limited space in CHPS facilities, particularly in temporary facilities. | Interim CHPS facilities are being replaced by properly constructed facilities. Plans and prospects should be communicated to communities to ensure involvement. |
Emergency service capabilities | Few communities are reached by ambulances. Community engagement is lacking. | Urgently needed scale-up is needed, based on successful demonstration of emergency care [13]. |
✓ Pregnancy related CHPS services | ||
• Delivery of all types of pregnancies | Delivery of uncomplicated pregnancies only; emergency obstetric care is often unavailable. | Scale-up emergency referral systems. Improve community-engagement in referral operations [14] |
• ANC, PNC, CWC | (No deviation from expectations) | The high coverage of ANC should be combined with worker immediate post-partum follow-up procedures and mortality audit methods that are restricted to facility delivery [8] |
• Availability of all GHS essential drugs at CHPS facilities | Limited range of essential drugs; limited capacity to administer first aid | Conduct a comprehensive review of logistics and supply operations [15] |
✓ CHPS family planning services: | ||
Comprehensive doorstep and CHPS facility-based family planning information and care | Family planning services in facilities only; limited community communication activities or household services. Absence of outreach to men | Review strategies of experimental projects and pilot studies that successfully introduced and sustained family planning [16] Implement proven male involvement strategies [17] |
✓ CHPS worker deployment and time use: | ||
CHPS never “closes”: Services are available on weekends, emergency services by resident CHO are available for 24 h, and clinical service hours start at 6 am. | • Services are usually limited to week days and routine office hours. • CHPS services are available for eight hours and unavailable at night. • Usual work hours start at 8 am to 9 am | Develop a revised policy on work hours and facilitative supervision that clarifies CHO coverage hours [18] |
Other expectations | ||
• Outreach and services that promote accessible safe water and sanitation | Limited focus on community water and sanitation | Develop community outreach that utilizes traditional communication mechanisms for consensus building and social action |
• Addressing social discord or spousal problems that restrict access to CHPS care. | Gender and social problems are neglected. |