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Background: The Ghana Community-based Health Planning and Services (CHPS) initiative is a national strategy for improving access to primary health care services for underserved communities. Following a successful trial in the North Eastern part of the country, CHPS was adopted as Ghana’s flagship programme for achieving the Universal Health Coverage. Recent empirical evidence suggests, however, that scale-up of CHPS has not necessarily replicated the successes of the pilot study. This study examines the community’s perspective of the performance of CHPS and how the scale up could potentially align with the original experimental study. Method: Applying a qualitative research methodology, this study analysed transcripts from 20 focus group discussions (FGDs) in four functional CHPS zones in separate districts of the Northern and Volta Regions of Ghana to understand the community’s assessment of CHPS. The study employed the thematic analysis to explore the content of the CHPS service provision, delivery and how community members feel about the service. In addition, ordinary least regression model was applied in interpreting 126 scores consigned to CHPS by the study respondents. Results: Two broad areas of consensus were observed: general favourable and general unfavourable thematic areas. Favourable themes were informed by approval, appreciation, hard work and recognition of excellent services. The unfavourable thematic area was informed by rudeness, extortion, inappropriate and unprofessional behaviour, lack of basic equipment and disappointments. The findings show that mothers of children under the age of five, adolescent girls without children, and community leaders generally expressed favourable perceptions of CHPS while fathers of children under the age of five and adolescent boys without children had unfavourable expressions about the CHPS program. A narrow focus on maternal and child health explains the demographic divide on the perception of CHPS. The study revealed wide disparities in actual CHPS deliverables and community expectations. Conclusions: A communication gap between health care providers and community members explains the high and unrealistic expectations of CHPS. Efforts to improve program acceptability and impact should address the need for more general outreach to social networks and men rather than a sole focus on facility-based maternal and child health care.
Qualitative Focus Group Discussions (FGDs), an approach that has been described as a “thinking society in miniature” [22], was employed to understand CHPS and its functions from the perspective of community members. The study was conducted in four villages, one each in four districts of the Volta and Northern Regions of Ghana. In each district, a community with an active CHPS compound was selected with the guidance of DHMT. The two communities in the Volta Region of Ghana are denoted as V1 and V2 whilst those in the Northern Region are denoted as N1 and N2. The communities were: Avedo (V1) in Central Tongu; Agoufie (V2) in Nkwanta South; Galwei (N1) in Gushiegu; and Mbanayilli (N2) in Kumbungu districts. Populations in both Northern and Volta Regions are largely rural and deprived in terms of health care provision. Christianity is the predominant religion in the Volta Region whilst Islam is the dominant religion in the Northern Region of Ghana. Specifically, participants in V1 and V2 were Christians and Traditionalists, while those N1 and N2 participants were predominantly Muslims. The age composition of participants was similar across localities. Five focus group discussions (FGDs) were held in each community (Additional file 1). Focus group discussants comprised mothers and fathers of children below 5 years, male and female adolescents without children and community leaders. Community characteristics differed. V1 participants were mainly secondary school educated, while most V2 participants were uneducated. In all the communities, adolescent girls’ and boys’ groups who participated in the study had some primary education. Recruitment of participants was also strategically undertaken to ensure participants cut across different religious denominations. Table 1 describes the characteristics of the study participants. Demographic characteristics of respondents Note: Secondary education and above consists of Middle School, Junior High School, Senior High School, Secondary, Technical School, and Tertiary education Focus group discussions lasted between one to 2 hours. Six to eight respondents were recruited for each Focus Group Discussion (FGDs). There was a total of 126 participants in all (n = 126). The discussions were guided by a semi-structured interview guide. Participants were allowed to freely express their opinions, feelings and attitudes about the provision of health care services by CHPS in their community. Sessions were conducted in prevailing local languages. This permitted community members to determine the direction of discussion emphasizing their health needs and priorities. Interviewers were trained on appropriate ways of moderating FGDs. Discussions were recorded using a digital audio-recorder and transcribed verbatim by professional transcribers. Participatory action research was also used during the FDGs [23–25]. The participants were given a scale [1–10] to rate the services of CHPS. Numeric responses, were recorded for each participant. A total of 126 scores was recorded. Ordinary least regression model was applied to interpret the scores ascribed to CHPS by community members controlling for community and sex of respondent. During the discussion, the facilitators asked the participants to explain their scores. All transcripts were read thoroughly by a team of three to familiarize with the text and to have a feel of the discussions that ensued in the interview locations. Transcripts were coded as a team to ensure inter-coder reliability. Initially, codes were sorted into organizing themes and shared amongst the analysis team. While the three analysts worked independently on the transcripts, the results of the analysis were shared via a Google Drive folder. The results of the first round of coding by the independent analysts were subsequently reviewed collectively for consistency and identification of points of convergence, divergence and absences. Points of convergence were described as dominant themes while areas of divergence were described as less dominant themes. The themes and the frequency of occurrence in each transcript was noted. The analysis identified two broad areas of consensus: positive perceptions/attributions and negative perceptions/attributions. Positive and negative scores were noted in the explanation’s participants consigned to the scores. Themes associated with approval, appreciation, recognition of excellent services and hard work by CHPS staff were classified as positive perceptions. Other themes such as rudeness, extortion, inappropriate and unprofessional behaviour, lack of basic equipment and disappointment were classified as negative attributions. Explanations provided by the community members for the scores were categorized into four thematic areas: 1. Community sense of pride and value of CHPS 2. Perceptions of service quality, 3. Views on the adequacy of the CHPS services package, and 4. Perceptions on the benefits of CHPS services.
