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Background: Within the integrated community case management of childhood illnesses (iCCM) programme, the traditional health promotion and prevention role of community health workers (CHWs) has been expanded to treatment. Understanding both the impact and the implementation experience of this expanded role are important. In evaluating UNICEF’s implementation of iCCM, this qualitative case study explores the implementation experience in Ghana. Methods and Findings: Data were collected through a rapid appraisal using focus groups and individual interviews during a field visit in May 2013 to Accra and the Northern Region of Ghana. We sought to understand the experience of iCCM from the perspective of locally based UNICEF staff, their partners, researchers, Ghana health services management staff, CHWs and their supervisors, nurses in health facilities and mothers receiving the service. Our analysis of the findings showed that there is an appreciation both by mothers and by facility level staff for the contribution of CHWs. Appreciation was expressed for the localisation of the treatment of childhood illness, thus saving mothers from the effort and expense of having to seek treatment outside of the village. Despite an overall expression of value for the expanded role of CHWs, we also found that there were problems in supporting and sustaining their efforts. The data showed concern around CHWs being unpaid, poorly supervised, regularly out of stock, lacking in essential equipment and remaining outside the formal health system. Conclusions: Expanding the roles of CHWs is important and can be valuable, but contextual and health system factors threaten the sustainability of iCCM in Ghana. In this and other implementation sites, policymakers and key donors need to take into account historical lessons from the CHWliterature, while exploring innovative and sustainable mechanisms to secure the programme as part of a government owned and government led strategy. Copyright:
This descriptive qualitative study [30] by rapid appraisal [31, 32] of the IHSS intervention in Northern Ghana forms part of a larger evaluation of the intervention in 6 African countries [29]. This broader evaluation encompasses both quantitative measures of coverage, impact, effectiveness and costs as well as qualitative exploration of implementation experience in each country. The full set of reports, including methods for the broader evaluation, can be found at http://www.mrc.ac.za/healthsystems/publications.htm. Between January 2008 and 31 May 2013 UNICEF, with funding from the Department of Foreign Affairs, Trade and Development, Canada (DFATD), supported the implementation of the IHSS programme in four regions of Ghana (Central, Upper East, Upper West and Northern) [15]. The aim of the programme was to support the High Impact Rapid Delivery (HIRD) strategy of the Government of Ghana, which began in 2007 and aimed to increase access to evidence-based high impact interventions to reduce maternal and child mortality [15]. During phase one of the IHSS the focus was on providing support for strengthening immunisations, vitamin A supplementation, infant and young child feeding, procuring and distributing insecticide treated nets, training and quality improvement. Implementation of iCCM of diarrhoea, malaria and pneumonia started in late 2010. Qualitative data were gathered through rapid appraisal [31, 32] during a 9 day country visit to Ghana which took place in May 2013. The data were collected by three senior researchers (KD, TD and ED), all of whom are women. Collectively they have training in social science research methods, public health and health systems research. The researchers engaged in individual interviews, focus group discussions and field visits [30, 33–35]. This involved speaking with key informants in Accra and Tamale (capital of the Northern region), as well as visits to local health centres and villages surrounding Tamale. Where necessary (in interviews with mothers, CBAs and CBA supervisors), the services of interpreters were used. Although the interpreters were provided by the GHS, several of the interviewees understood English well enough to check the accuracy of the translation. All interviews took place either at the offices of the interviewees, at a district office or health centre, or in the communities. Interviews were audio recorded and the researchers took field notes. None of the interviews or focus groups were repeated. In advance of the country visit we sent a proposed list of interviewees to the UNICEF country team, who then assisted with pre-scheduling appointments. In compiling this list we gave consideration to gaining as wide a range of opinion as possible so as to ensure a fair representation of how the implementation of iCCM was experienced in Ghana [36]. In choosing the health centres and villages we ensured representation between sites that were close to Tamale town centre as well visiting remote villages where access to all services was poor. Informants included UNICEF staff (9) and other partners and researchers (5), national and regional GHS staff (13), CBA supervisors/zonal coordinators (6), nurses in health facilities (11), CBAs (24) and mothers (37) and one village chief (1) [Table 1]. The zonal coordinators were all older men (40 years and older) who had been previously engaged as CBAs in guinea worm eradication. None of those we interviewed had jobs beyond the intervention and they did not generate their own income outside of the intervention. The CBAs were specifically engaged for this intervention, with all of them having 4 years experience. All of those we interviewed generated their own income outside of the intervention including being farmers, petty traders, and carpenters. They were younger than the zonal coordinators, with ages ranging from 21 years old to 32 years old. Of those we interviewed 15 were male and 9 were female. The mothers who participated had an age range of between 20 and 40 years old, with between 1 and 11 children. On the last day in the field an initial reflection of our insights was presented to UNICEF staff. Thereafter we conducted a simple manifest analysis of the qualitative material [30, 37]. Since this was not an ethnographic study we were simply interested in what happened and what was experienced rather than trying to understand the deeper meaning of the experience. Exploring such meaning was not our evaluation intention and would have required a different study design. We analysed the data both deductively and inductively [38]. Deductively, we sought to find answers to predefined questions (e.g. how did this intervention fit within the policy environment? or, what evidence was there of health systems strengthening on the ground?). Inductively, we tried to understand what new information and insights could be gleaned from the interviews and our experiences of visiting the field. The analysis was based on the typed interview and focus group notes as well as reflections from the field. This material was repeatedly reviewed by KD and TD. We annotated our reflections while reading, and then came together to discuss, compare and critique our insights. Based on this analysis the data were electronically (using a word processor) grouped into categories, the results of which are reported in narrative form in this paper. This study received ethical approval from the South African Medical Research Council (EC026-9/2012). The interview and focus group processes, including the consent procedures, were also approved by the ethics committee. Before engaging with participants we explained in detail who we were, why we were visiting and why we wanted to speak with them. When necessary, especially with community members, CBAs and their supervisors, we used the services of a translator to explain our research aim and the consenting process. In all cases we tried to ensure that participants understood what we were asking them to agree to, and what their rights were, especially the right not to participate. Where participants were literate we obtained signed informed consent from them. For those who were not, consent was obtained orally. Since we could not record the oral submissions, we allowed participants the opportunity to leave before we started the audio recording. However, as has been our previous experience, no one left beforehand but occasionally participants would leave during the interview. We were guided by UNICEF and GHS field staff as to when it was necessary to obtain permission from community leaders such as the chief, and in such instances included their opinions on iCCM as part of our data.
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