Background: Although community participation remains an essential component globally in healthcare service planning, evidence of how rural communities participate in the planning of rural-based healthcare programs has less been explored in Sub-Saharan Africa. Objective: We explored communities’ participation in health care planning in hard-to-reach communities, within the context of Integrated Community Case Management (iCCM), a community-based health program implemented in Ghana. Methods: Qualitative data were collected from eleven (11) hard-to-reach communities through Focus Group Discussions (FGDs), Key Informant Interviews (KIIs) as well as district-level studies (Nadowli-Kaleo, and WA East districts of Ghana). The Rifkin’s spider-gram, framework, for measuring and evaluating community participation in healthcare planning was adapted for the study. The results: The study found that community participation was superficially conducted by the CHOs. A holistic community needs assessment to create awareness, foster a common understanding of health situations, collaboration, acceptance and ownership of the program were indiscernible. Rather, it took the form of an event, expert-led-definition, devoid of coherence to build locals understanding to gain their support as beneficiaries of the program. Consequently, some of the key requirements of the program, such as resource mobilization by rural residents, Community-based monitoring of the program and the act of leadership towards sustainability of the program were not explicitly found in the beneficiaries’ communities. Conclusion and recommendation: The study concludes that there is a need to expand the concept of community involvement in iCCM to facilitate communities’ contribution to their healthcare. Also, a transdisciplinary approach is required for engineering and scaling up community-based health programs, empowering VHCs, CBHVs and CHAs to realize success.
The study was conducted in 11 hard-to-reach communities (rural communities) in the Wa East and Nadowli-Kaleo districts of the Upper West Region, Ghana, comprising five (5) communities in the Wa East district and six (6) communities in the Nadowli-Kaleo district. The communities included Chang, Chaangu, Chaggu, Giland, Habanikole, Mantari, Naaha, Sirro, Viehaa, Yiziire, and Nirri. These communities were purposively selected due to their hard-to-reach nature. Firstly, they are characterized by dispersed settlement pattern and located far away from the major townships of the districts and the regional capital (Wa), amid very low access to healthcare services [37]. Secondly, both districts record the prevailing incidence of under-five and maternal mortality [38]. Thirdly, both districts were characterized by rural communities and dominated by peasant farmers, who cannot afford the cost of transportation to and from the major health facilities [38]. Fourthly, both districts and the communities have limited health facilities amid inadequate transport modes and poor road networks to major health centres (see Fig. 1). Map of Wa East and Nadowli-Kaleo districts showing the study communities The poor road network in both districts’ challenges accesses to health. In the Wa East district, over 40% of the roads are less accessible all-year-round [38]. The worse situation occurs between the period of July and September, where most communities in the district get cut-off beyond vehicular reach [37]. Although the state transport, Metro Mass Transit (MMT) is the most reliable means of transport between the regional capital (Wa) and the districts, poor road network challenges all-year-round mobility, especially in the Wa East district [37]. These characteristics necessitated the introduction of the iCCM program. The study employed the qualitative research approach to explore in in-depth, community participation in healthcare planning in hard-to-reach communities in the context of the iCCM [39]. Specifically, the local health actors involved, how they were selected, the needs assessment, locally driven monitoring of the program, resource mobilization and the act of leadership. The qualitative approach was useful in exploring key variables postulated in the Spider-gram, framework on community participation in healthcare service planning [16]. To adequately situate the framework with the result of the study, we reviewed related literature from articles on community participation in healthcare planning in Sub-Saharan Africa [35, 36, 40, 41], and health policy documents, reports and articles in Ghana [3, 12, 14, 25, 33, 38]. We then collected qualitative data on Community health, the actors involved, the conduct of the need’s assessment, the selection of the CBHVs, and how that influenced community-driven monitoring of the process, resources mobilization and leadership for sustainability. Data were collected through Focus Group Discussion (FGDs) and Key Informant Interviews (KIIs) methods. Twenty (22) Focus Groups Discussions were conducted comprising eleven (11) women and elven (11) men groups with the used of an in-depth interview guide (structured interviews guide). The number of participants per FGDs ranged between 6 and 12 persons and aged between 18 and 70 years. All the participants have lived in the study communities for more than 10 years, as the basis of their rich knowledge and experiences about the iCCM program. Given that the study centred on the general perception and participation of the communities, the face-to-face discussions stimulated debate among the participants and enabled them to come to terms with the realities. However, continuous probing during the FGDs sessions enabled the participants to brainstorm and openly discussed issues about the iCCM program. At the end of each discussion session, the participants were asked to rate their perceived level of participation in the planning of the iCCM in their communities using a 5-point scale (see Table Table1),1), based on the adapted indicators. Each of the interviews’ session lasted approximately, 1 h. 15 min, and the discussions were recorded with audio recorders alongside note-taking. Key informant interviews were conducted with eleven (11) purposively selected key community-level leaders (Community Health Agents) either the Chiefs, Queen mothers, Assembly members, Clergies, Village health Committee, Care-givers or the Community Association head. Eleven (11) Community-based health Volunteers (CBHVs) were interviewed from each community. The in-depth interview guide was used in the form of a face-to-face conversation. The selection of the key informants was guided by the Community-Health Officers (CHOs) due to their direct interactions with the community local actors under the iCCM program. The selected CBHVs were identified in each community through the effort of the Community Health Agents (CHAs). Data was also collected on the needs assessment, the selection of the CBHV, Community-driven monitoring, resources mobilization and leadership. The interview session for each of the KII lasted between 30 to 50 min. In the health institutions, Key Informant Interviews (KIIs) were conducted with six (6) purposively sampled health professionals. The District iCCM Coordinators (DICs), the Health Promotion Officers (HPO), of the two districts, in addition to two (2) Community Health Officers (CHOs). The interviews were conducted through face-to-face conversation alongside note-taking and audio recording, by two native speakers of the local dialects (Dagaare and Waala), also the authors of this paper. The data was validated through community durbars in the respective communities. The consents of the respondents were sought and the interviews recorded with audio recorders for transcription. The results obtained were discussed with the community members for consistency. Indicators that received the highest ranked were discussed and agreed upon as either true reflection or not, whiles conflicting and contradictory views were clarified at the focus group discussion sessions. The research received ethical clearance and approval from the Ethical Committee of the Graduate School of Tropical Medicine and Global Health, Nagasaki University and the Ghana Health Service Ethical Review Committee. The data was collected between January and March 2018 and validated in February 2019. Due to the remote nature of the sampled communities, three (3) motorbikes were used as the means of transport to the communities by the researchers. The data recorded were transcribed, reviewed and exported into Dedoose software a qualitative software for coding. Dedoose software is suitable for analysing data collected in the form of text, photos, audio and video from either qualitative or mixed-method research. In the context of our study, the Dedoose software was used to analyse the text of the qualitative data gathered. The main themes in the sentences were identified, named and the concept given to control the researchers’ subjectivity. All data items were coded and collated with their relevant data excerpts.
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