Assessing participation in a community-based health planning and services programme in Ghana

Inspired by the Alma Ata commitment to primary health care, and regarded as a bold departure from bureaucratic models of health service delivery, CHPS is a national health policy initiative that was adopted in 1999 [11]. The initiative, as a strategy to increase rural access to health care service while empowering local communities to take greater control over their health, sought to promote community-driven health care services, with technical support from the central Ghana Health Service. The CHPS initiative is an extension of the Navrongo experiment (pilot project of CHPS). Initiated in 1994, it advanced the idea that the mobilisation of traditional systems of leadership, resources, communication and governance had the potential of increasing health-care services accessibility, reducing child and maternal mortality whilst improving rural-population’s overall health (ibid.). At a National Health Forum in 1999, the Ghana Health Service disseminated results from the Navrongo experiment and subsequently drafted a policy statement coining the acronym and legitimizing CHPS as a national community health care initiative with the Ghana Health Service (GHS) assuming oversight responsibility.

The CHPS strategy advocates the systematic planning and implementation of primary health care facilities^a and activities with active participation of community leaders and members. In practice, this is achieved through the mobilization of community leadership, decision making systems and resources in within defined catchment areas (zones) [12]. CHPS is integral in other Ghanaian government policy agendas including the current National Health Policy. It has been cited as a major healthcare care reform strategy in Africa with health services adapting to local needs and circumstances [11]. In this paper we draw on a social psychological understanding of participation and the spider-gram method to assess community members’ experiences of participation in this promising programme and explore what more can be done to make programmes of this nature more participatory.

Much scholarly work has highlighted the difficulties of evaluating community participation in health interventions [2, 13, 14]. With growing interest and pressure to involve local communities in global health practice, there is a pressing need to develop theoretical and methodological tools that assess the processes underlying participatory programmes. In this paper we explore how combining Campbell and Jovchelovitch’s [8] conceptualisation of a ‘Social Psychology of Participation’ and Rifkin et al’s [15] ‘Spider-gram’ can be used to assess participation in community-based health care programmes. We introduce each in turn.

Much of the literature on community participation is driven by ideological and political commitments to participation, contested and framed either as a basic human right, a pragmatic strategy to utilise services or as pathway to empowerment [16]. In this paper we draw on the theoretical insights of a social psychology of participation, which leans towards the model of empowerment. The social psychology of community participation was promulgated by Campbell and Jovchelovitch [8] as a conceptual framework for action research seeking to explore the pathways between community participation, health and social development. The starting point of this framework is that the poor and marginalised often lack a sense of control over their health and well-being, leading to a sense of fatalism, and a tendency to wait for outside actors and agencies to take control of local health problems. Against this background, the framework seeks to draw attention to ways in which communities can be ‘empowered’ to exercise greater agency over their health, by changing health-damaging behaviours where possible, and making optimal use of available health services. Drawing on Habermas’ [17] idealised notion of the public sphere, the framework advocates that for participation to offer community empowerment, it should take place in a social space (public sphere) where all participants (in this case health service providers and users) have the right to participate fully in the design, implementation and evaluation of health programmes, with programmes being driven by a synthesis of ‘local’ and ‘expert’ knowledge, with both knowledge systems being accorded equal respect. Freire [18] suggests participation is most likely to empower marginalised communities to exercise greater control of their lives (and more specifically their health) if it is framed within a dialogical and facilitative approach through knowledge negotiation and power transfer from health professional to communities [19, 20].

Health-enabling community participation should involve genuine sharing of power amongst health experts and decision makers on the one hand, and marginalised groups on the other [21]. Such an approach is said to build a sense of community ownership of local problems (as opposed to a sense that such problems can only be solved by outside professionals), and to encourage communities to contribute to the development of concrete strategies through which they can improve their health [22, 23]. This approach resonates with the views of Robert Chambers who argues that poor communities can be empowered by taking responsibility and action in cases where experts are ready to share power and control over programs [24].

The Spider-gram methodology was developed by Rifkin et al., [15] to measure, visualise and locate levels of community participation in health programmes on a continuum. From an analysis of over 200 case studies [25], Rifkin and colleagues identified five indicators: Needs assessment refers to the roles played by programme beneficiaries in identifying their health needs and in designing the community intervention. Leadership emphasises the inclusiveness and representativeness of all community interests groups. Organisation refers to the extent to which new community interventions integrate or collaborate with pre-existing community structures or networks. Resource mobilization refers to communities’ ability to mobilise and contribute resources towards a community–based intervention. Management refers to community’s capacity to take decisions about the programmes’ direction and development.

Each indicator is located on a continuum. The original spider-gram plotted these indicators on a continuum that at one end marked narrow participation and at the other marked wide participation. This continuum was modified by Draper et al. [2] to place mobilization at one end and empowerment at the other. For this research the original continuum was used. The continua are linked together at the narrow end to form a pentagram. Each continuum is used to grade how wide or narrow community participation is. In a group setting, community members are asked to grade, from 1 to 5, the level of participation they felt was involved in the programme, with 1 reflecting a low level of participation and 5 reflecting the highest level of participation. To illustrate this, as well as to operationalize these indicators in relation to a continuum of participation, we have in Table 1 applied the principles of spider-grams to the CHPS programme.

Spider-grams can illustrate levels of community participation as perceived by community members (see Figure 1) and be used to comparatively assess community participation across programmes, with different participants in the same programme as well as tracking to see changes in community level of participation in a particular programme over time. In view of its simplicity, applicability, and wide acceptance, it has been applied in many different contexts and studies [26‐32].

The study was conducted in the Wa Municipal of the Upper West Region of Ghana, West Africa. The Municipality, according to the 2010 Population and Housing Census has a total population of 116,460. Waala is the main tribe in the Municipality although other ethnic and tribal groupings are resident in the municipal. In terms of healthcare delivery, there is a government hospital in the capital (Wa) of the Municipality and a few private clinics. Geographical accessibility to specialist health care is therefore not only difficult for the majority of people living in this part of the country but also skewed in favour of communities located within the Wa Municipal.

Optimising community access to healthcare and other social services in the region has been a long-standing challenge for the government of Ghana. Since the inception of the CHPS initiative in 1999, the government, with support from the Japan International Cooperation Agency, has been committed to scaling up CHPS facilities throughout the region. CHPS facilities are health care delivery centres, which are meant to be managed and run by the communities they serve. In this study we assess the level of participation by community members in the planning and running of the Nachanta CHPS health care facility, which is one of fourteen CHPS facilities in the Wa Municipality of the Upper West Region. Nachanta was purposively selected for this study primarily for being an averagely performing CHPS zone according to the Municipal Health Directorate and thus avoiding a skewed focus on either good or poorly performing CHPS facilities. Secondly, community members had participated in a discussion about CHPS on a local radio station and had therefore shown a previous interest in discussing their experiences of CHPS. The Nachanta CHPS opened in June 2008 and is jointly managed by three communities; Nakori, Tampieni and Chansa with a total population of 4,237 people. The community members are predominantly subsistence farmers cultivating crops such as maise, beans and rice. The Nachanta CHPS facility has been running for nearly three years at the time of the study.

To develop a holistic understanding of community participation in Nachanta CHPS, we examined the perspectives of three groups of stakeholders. We involved both service providers (n=3; 67% female, mean age of 52), users (n=12; 50% female, mean age of 46) and those at the interface, serving a role at the local community health committee (n=4; 50% female, mean age of 50). Service users in this study refer to adult community members from communities (Nakori, Tampieni and Chansa) within the Nachanta health centre catchment area. They were purposefully recruited [33], pages 169–186 through convenience sampling, based on their close proximity to the location of the interviews, interest and availability to participate. Service providers and community health committee members were recruited through criterion sampling, with the criteria either being the nature of their involvement in the provision of services or active participation in the local community health committee. Deliberate efforts were made to recruit a mix of male and female informants to explore the gender dimension of community participation.

Data were collected during two weeks of April, 2011. Before the data collection period, two preliminary visits were made to the study communities by the research assistants. The first visit was to sensitise the communities and meet with the opinion leaders to discuss the study and formally seek their consent and approval. Through this process, a rapport was established between leaders and research assistants. Issues of venue for the interviews, time period for the interviews, focus groups discussions and the community conversation were clarified in the second visit. The visits offered the researchers the opportunity to respond to questions posed by community members and also identified potential respondents. Data was collected by two research assistants in the local Waala language and supervised by the first author, all three of whom are local social science graduates with a wealth of experience in social research. Furthermore, they understood the local language and socio-cultural context of the study area. A quality assurance check list was developed to enable the first author to check data quality, including the translation and transcription of data.

As Table 2 indicates, data were collected in three different stages, with individual interviews and focus group discussions leading to a ‘community conversation’ [34] where all the study participants came together to discuss and draw up a spider-gram reflecting their consensus on the level of community participation that characterised the Nachanta CHPS. As a result of this step-by-step process, informants participated to varying degrees. For example, only two community health committee members participated in individual interviews. An additional two health committee members joined the focus group discussions, of which one did not have the time to subsequently participate in the community conversation.

We conducted a total of 17 in-depth individual interviews: 3 with service providers; 12 with service users; and 2 with community health committee members. Those who were individually interviewed were subsequently invited to participate in one of two focus group discussions made up of a mix of service users, providers and community health committee members to spark debate and enrich their responses in the process. The focus group discussions were segregated according to gender to ensure that weaker voices (most frequently women in this context) are not overshadowed by more powerful members of the group in the community (most frequently men). Two additional community health committee members joined the focus group discussions. The female focus group discussion consisted of 2 community health committee members and 6 service users, whilst the male focus group was made up of 1 service provider, 2 community health committee members and 6 service users (see Table 2).

The interviews and focus group discussions were semi-structured and followed a topic guide with open-ended questions, which focused on the central research themes of needs assessment, management, organisation, resource mobilisation, and leadership. This allowed the researchers to both stay on topic whilst also having the flexibility to explore surprising but relevant responses further through prompts and follow-up questions. The two focus group discussions lasted between 115 and 130 minutes whilst individual interviews lasted between 50 and 60 minutes. After the interviews and the focus group discussions were completed, we invited all the informants to participate in a community conversation with the aim of collectively evaluating community participation in Nachanta CHPS. The spider-gram enabled a discussion and process to take place that culminated in a consensus, ranking each indicator of community participation a score as illustrated in Table 1 (see Table 3 and Figure 2 for the scores of the participants).

As we sought to do a thematic analysis, transcripts of both individual interviews and focus group discussions were imported into Atlas.Ti, a qualitative software package, for coding. Through a process of reading and re-reading, data were categorised, giving rise to 168 codes, reflecting the wealth of themes emerging from the interviews. We do not seek to report on all of these codes, but following the thematic network analysis procedure as outlined by Attride-Stirling [35], identified codes from the larger pool of codes based on their recurrence and interconnectivity with the conceptual frameworks and the reviewed literature, a process that resulted in selection of 32 codes. In the second step, basic themes were explored and both facilitating and barriers to community participation themes were noted, paying particular attention to the different views of our three groups of study participants. These were further examined into higher organising themes (step three). In step four, five pre-determined themes constituted our global themes. At this stage, the global themes were categorised according to their resonance with the predetermined thematic areas suggested by Rifkin et al. [15]. Table 3 depicts the coding framework and illustrates how the themes are connected as we moved from codes to basic, organising and global themes. We use the coding framework to structure our discussion of findings.

From the interviews, the view shared by all participants was that the community did not play any role in identifying their health needs or designing CHPS. From their accounts, the program was designed by health experts from Wa without their inputs or participation. Despite this pattern, the study revealed community members welcomed and supported the program because it significantly resonated with their health needs. The excerpt below is a male participant’s reflection on this.

Contrary to the dominant view that their needs had been pre-defined by the service providers, a minority of participants indicated there were indeed community consultations and meetings about the CHPS program before it was brought to them. This was echoed further by interviews from the service providers namely the Municipal CHPS coordinator and the community health committee chairman. The chairman reported they held three meetings with them on issues of implementation and these were discussed and agreed by all during the community meetings before the start of the CHPS implementation. He intimated the meetings were organised for community members to reach a consensus on how the programme could well be implemented. Below is an expert from the committee chairman in this regard.

In short, service providers and some service users appeared to be more aware of opportunities for participation than other service users. However, in reaching a consensus on their level of participation, service users rated their participation in needs assessment at point-1 on the spider-gram indicating very low level of participation.

Under leadership, different views were expressed by both service users and service providers regarding the leadership style and composition of the community health committee. Interviews from majority of the service providers revealed that the leadership style and composition of the community health committee represented all interest groups and that its activities and decisions served their interests and not that of the committee or any individual. Few service users held contrary views to this. Affirming the trust community members had of the community health committee’s leadership role, a participant ran the following commentary:

However, all informants were unanimous that programme leadership was completely male dominated.

Another informant commented rhetorically on the complete absence of female representation in the CHPS process:

‘…assemblyman, assemblyman, are there even women in that your committee? I mean the committee in charge of CHPS in the community?’ (Male service user in focus group discussion)

The community health committee has decision making powers with less community involvement. Community members only get involved when decisions have been made and they get informed of the roles expected of them. Following deliberations on where to peg their role in leadership, point 3 of the spider-gram was reached by service users.

Findings from the interviews revealed the communities had made significant ‘in kind’ and ‘cash’ contributions to support the program. Contributions in kind took the form of water, sand, purchase of stones, among others for the construction and maintenance of CHPS, as well as the labour to build and sustain the buildings. Contributions were also made in cash to support the building and maintenance of the CHPS program.

Our findings suggested that contributions to labour and materials were made by a wide range of community members irrespective of their economic status or gender. However, inputs were gender differentiated, with men and women. The men contributions were in the form of labour, cash, digging of sand, etc. whilst the women carried water, sand, cleaning the surroundings of CHPS.

Madam Fati! You know everybody’s situation in these communities. We are all poor. Once you are living in a community like this, you are considered poor or else you would be living around Wa or the Kambali town areas or the Xavier community. We all share the same problems and so no one is higher, lower or expected to be given any preferential treatment. But contribution was segregated by gender. You know we can’t contribute equally, we have our share to contribute and our male counterparts have theirs. But for us, we all contribute equally; if you don’t, your fellow women will discount you’. (Female service user in focus group discussion)

Also, service users said that decisions on contributions were exclusively discharged by the community health committee, that is, decisions were vertically made. The community health committee had absolute and unquestionable decision making powers over what needed to be contributed. However, community members shared the view that their support of the programme has empowered them. Corroborating with data elicited from the in-depth interviews, the two focus groups affirmed that their contribution and support to implement CHPS has been tremendous and as a result they firmly rated the community’s contribution on the spider-gram at point 5.

The findings showed that CHPS was independently managed by the local community health committee without any outsider influence. Some service users in the interviews also spoke and expressed confidence in how the community health committee was managing and overseeing the CHPS programme implementation. A participant highlighted this point in the following extract:

‘…Certainly! The committee is managing the programme very well without external or outside (GHS) influence. We might be small at the moment and not representing all but this is a view widely held in these three communities if you want to enquire further to establish the fact’. (Female service user in focus group discussion)

Also, the study indicated that management and decision making structures were vested under the authority of the community health committee who made decisions vertically without full community members’ engagement. Community members (service users) were only at the receiving end of decisions unilaterally made by the community health committee.

‘ Hmmm … what can we say since we are not them? I mean the committee. Ok. From outside point of view, I think everything is working alright without external interference. We would have been made aware if there were such issues’. (Male service user in individual interview)

Again, female representation in the management structures was silent as findings indicate a male-dominated management style. The service users when prompted about their view on such an arrangement did not have any reservation about it. They appeared to be satisfied with what they regarded as the good management roles and decision making structures coordinated by the committee. Regarding opportunities for management capacity building, the committee chairman indicated that they had no access to capacity and skills training programmes to enhance their capacity to manage the programme. On the whole, in rating their participation in managing the CHPS on the spider-gram, majority of service users solidly agreed on point-4 as the extent to which they participate in the program although this did not fully reflect the positions held by all services users as some few service users held contrary views regarding their level of participation in managing CHPS.

Findings from the study revealed that the CHPS programme successfully integrated itself into pre- existing community structures that predated the establishment of the CHPS. Some of these structures that had existed in the community prior to the advent of the CHPS programme the study revealed include a unit committee, health volunteers and traditional birth attendants. The study gathered that all these community structures were all absorbed and fully integrated into the CHPS programme in order to avert any confrontation or conflict between CHPS and the community structures. In highlighting on the degree of CHPS integration with the community structures, a health committee member gave the following commentary:

Following this, participants deliberated on where to rate their level of community participation on the spider-gram. Subsequently, participants unanimously agreed that pre-existing community structures were fully integrated into the CHPS programme and so they rated it at point 5.