Community perceptions of universal health coverage in eight districts of the Northern and Volta regions of Ghana

Background: Ever since Ghana embraced the 1978 Alma-Ata Declaration, it has consigned priority to achieving ‘Health for All.’ The Community-based Health Planning and Services (CHPS) Initiative was established to close gaps in geographic access to services and health equity. CHPS is Ghana’s flagship Universal Health Coverage (UHC) Initiative and will soon completely cover the country with community-located services. Objectives: This paper aims to identify community perceptions of gaps in CHPS maternal and child health services that detract from its UHC goals and to elicit advice on how the contribution of CHPS to UHC can be improved. Method: Three dimensions of access to CHPS care were investigated: geographic, social, and financial. Focus group data were collected in 40 sessions conducted in eight communities located in two districts each of the Northern and Volta Regions. Groups were comprised of 327 participants representing four types of potential clientele: mothers and fathers of children under 5, young men and young women ages 15–24. Results: Posting trained primary health-care nurses to community locations as a means of improving primary health-care access is emphatically supported by focus group participants, even in localities where CHPS is not yet functioning. Despite this consensus, comments on CHPS activities suggest that CHPS services are often compromised by cultural, financial, and familial constraints to women’s health-seeking autonomy and by programmatic lapses constrain implementation of key components of care. Respondents seek improvements in the quality of care, community engagement activities, expansion of the range of services to include emergency referral services, and enhancement of clinical health insurance coverage to include preventive health services. Conclusion: Improving geographic and financial access to CHPS facilities is essential to UHC, but responding to community need for improved outreach, and service quality is equivalently critical to achieving this goal.

This study is a component of the application of the WHO paradigm for evidence-driven scaling up that is known as the ‘Strategic Approach’ for assessing community perceptions of problems to be solved by implementation research [40–42]. Phase 1 in this paradigm is comprised of qualitative formative research that identifies problems and clarifies interventions with thematic analysis. Results identify possible operational improvements that can be subsequently put to trial. Based on the outcome of Phase 2 experimentation, replication studies and scaling up of systems reform follow [21,43]. This study was designed to clarify CHPS reform themes for trial in the CHPS+ initiative [35]. The regional coverage of CHPS in the Volta and Northern Regions is typical of national coverage (Table 1), but health and survival indicators are indicative of greater levels of adversity that the national mortality rates (Table 1). In the Volta Region, the prevailing maternal mortality ratio is over double the national average. The Volta Region is poorer than the national standard, and the Northern Region is poorer still [44]. Women with no educational attainment comprise 28.3% of the Volta Region population versus 58.9% of all women in the Northern Region. The pattern is similar for men (15.3% versus 44.3%) in the Volta and Northern Regions, respectively, [44]. Estimates of key indicators of CHPS service coverage by study regions aDeaths to women during pregnancy and 42 days following delivery per 100,000 live births (2010–2015). bRates calculated as the number of deaths within 28 days of delivery per 1,000 live births. cRates calculated as the number of deaths between birth and 5 years of age per 1,000 live births. dPercent of surgical deliveries. ePercent of women aged 15–49 who are currently using any modern method of contraception. Sources [5,38,47,48]. These regional characteristics are reflected in the profile of focus group participants (Table 2). In the Northern Region, over 40% of the participants lacked any educational attainment (Kumbungu 41%; Gushiegu 44%). Study participants in Nkwanta South, a northern district of the Volta Region, had somewhat lower levels of educational attainment than Kumbungu or Gushiegu, with 61% lacking any education, 15% with primary education and only 11% with secondary education. Somewhat higher levels of educational attainment were evident in Central Tongu, where a majority of participants had middle-school educational attainment (56%) followed by primary (17%) and secondary education (16%). Thus, Northern Region residents, and study participants from that region, are more socio-economically disadvantaged than Volta Region residents. Numbers of focus group participants by SLD, type of participant and type of background characteristics of participants From April to May 2017, CHPS frontline workers were convened by District Health Management Teams (DHMT), informed about study plans, and requested to mobilize participants for group discussions. Sessions were conducted by 10 male and 10 female interviewers, all of whom were hired for the study and trained in focus group methods by social scientists affiliated with the University of Ghana Regional Institute for Population Studies (RIPS) and the University for Development Studies (UDS). The CHPS+ qualitative systems appraisal consisted of 57 FGDs. However, 17 sessions for GHS district staff members, CHOs, and volunteers were excluded from the analysis, yielding 40 sessions comprised of community participants that were convened across eight communities involving 327 participants separated for mothers and fathers of children under 5, young men and young women aged 15 to 24. One session included participation of an adolescent girl who was later discovered to be 13 years old. Although panels also involved leaders comprised of elders, opinion leaders, and chiefs (Table 2), analysis of their perspectives on CHPS appears elsewhere [28], as this investigation focuses on the views of actual or potential clientele of the programme. Sessions were conducted in communities within the four SLDs, half of which were purposefully selected among communities with functional CHPS operations while half were conducted among communities lacking functional CHPS. Discussions were conducted in local languages (Ewe, Dagbani, Likpakpaln and Twi) and subsequently translated and transcribed into English by experts in these languages. Male interviewers conducted sessions with adolescent boys, fathers and elders, while female interviewers conducted sessions involving women and adolescent girls. Interview durations ranged from 50 to 140 minutes. Interviewers instructed participants to reflect on their experiences with CHPS, perception of the programme, and the general system of healthcare serving their locality. Participants were asked to discuss their health-seeking behaviour, delivery preferences, views on mortality risks, and family planning services. Comparisons across discussion sessions were intended to elicit a depiction of the intersection of socio-cultural norms with actual CHPS health-care experiences, providing an ‘open system’ appraisal of the adequacy of CHPS embeddedness in the local social context [19]. Each session was planned to involve eight participants. However, the size of groups varied depending on regional availability and staff allocation – yielding a total of 327 participants. The average ages of participants were 33 years for mothers, 35 years for fathers, 18 years for young girls, 20 years for young boys, and 60 years for community leaders and elders. As Table 2 shows, Gushiegu and Kumbungu are mainly Muslim communities, whereas Central Tongu communities are predominantly Christian with a minority who are traditionalists (7%). Nkwanta South communities were also predominantly Christian (46%) although a significant minority were traditionalists (27%) or participants reporting no religion (24%). FGD guidelines invited open expressions of viewpoints on the CHPS programme by eliciting comment on the location of CHPS services and, for women, their preferred location for delivery services. Participants were encouraged to discuss their views on the causes of morbidity and mortality in their community and the role of CHPS in providing needed care. Operational features of CHPS were also discussed: service content, costs, perceptions of CHPS health-care utility and quality, the adequacy of its range of services, appropriateness attitudes and capabilities of CHPS staff, and constraints, if any, to accessing CHPS services or complying with clinical interventions or prescriptions. For each topic under discussion, participants were invited to discuss both positive and negative perceptions of the programme. For problems that were noted, participants were invited to discuss their recommendations for change. To facilitate systematic understanding of discussion contents, analyses of 40 community transcripts utilized the qualitative analysis software Atlas.ti version 7 [45,46]. Major themes were extracted by three coders using a coding frame initially developed by deploying all coders to a common transcript, and then applying this frame as a template for coding the remainder of the transcripts.

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