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Background. Maternal, Child Health and Nutrition improvement Project is a World Bank-funded project implemented in all then ten regions of Ghana, which aims at improving access and utilization of community-based maternal, child health, and nutrition services in order to accelerate progress. This study is aimed at determining the implementation status of the project in the Eastern region by evaluating the processes involved and identifying implementation barriers from the perspective of implementors. Methods. The study was a cross-sectional in design and employed a quantitative data collection approach in ten Community-based Health Planning and Services (CHPS) centres in five districts in the region. The project coordinators and Community Health Officers were interviewed using a structured questionnaire. The project implementation reports at the facility level were reviewed using a checklist. Tertile statistic was used to describe the status of the project implementation. Result. The finding from this study indicated “complete implementation status”for maternal, child health, and nutrition activities of the project. However, none of the facilities evaluated had satisfactorily implemented all the governance processes and were therefore rated as “partially complete.”The main implementation barriers emerged from the study were related to restrictions placed on the use of project funds and delays in the fund disbursement to CHPS facilities. Conclusion. The evidence gathered from the study showed very good implementation status for community-led maternal and child health service delivery, indicative of a positive response to the guidelines by service providers at the periphery and can have positive impact on the project’s objectives and goals. Governance component of the project, however, revealed inadequate alignment with guidelines which might have been influenced by the lack of knowledge as a result of lack of training for implementers. This therefore calls for in-service training and improved supportive supervision at both administrative and service delivery levels.
The study was a cross-sectional descriptive study, which employed quantitative approach to determine the current status of the key processes (governance, maternal health, child health, and nutrition services) of the MCHNP in the Eastern region of Ghana. The region is the sixth largest region in Ghana with a land area of 19,323 kilometres square. It has a population of 3,171,743, made up of 49% males and 51% females. There are 26 districts in the region, which are further demarcated into 183 administrative subdistricts; 18 of the 26 districts have at least one hospital. Other levels of health facilities abound in all the districts in the region. MCHNP is being implemented in all 183 subdistricts and 828 CHPS centres in the region. The project covers the entire population of the region. The project was designed to address the inequity gap in order to increase utilization of maternal and child health services. Within the participating communities, the project targets pregnant women and children under 2 years of age. Besides, the project also benefits other people in the community, especially children under 5 years, with wide range of community-based interventions such as the promotion of family planning, early registration of pregnant women for antenatal care, skilled delivery, exclusive breastfeeding, birth registration, and growth promotion among others [5]. The Regional Director of Health Services (RDHS) is accountable for implementing and tracking the project operations at the regional level, supported by the Director of Public Health, the Nutrition Officer, and regional Disease Control Officer. In line with the operating guidelines drawn up by Ghana Health Service (GHS), the District Director of Health Services (DDHS) coordinates the development and implementation of the district action plan for subprojects as well as monitoring project indicators, supported by the DHMT. For districts to develop context-relevant implementing strategies, the guidelines provide enough flexibility. The main change agents in the project are the CHO’s and CHVs, who carry out outreach programmes, home visits, and promote development operations. This initiative promotes the current community structures to mobilize members of the society, promote the selection and monitoring of community volunteers, and promote the monthly operations through periodic leadership conferences, which discuss advancement in the community. The volunteers help organize periodic community meetings to review the implementation process of the project. The project also utilizes current local structures to get community leaders to take responsibility for health and dietary problems in the community. The study purposefully selected 3 administrative levels—one Regional Health Directorate, five District Health Directorates, and ten (10) functional CHPS centres. Thus, a total of 16 facilities were evaluated. A simple random sampling method was used to select 5 districts, and in each district, 2 CHPS centres involved in the project were sampled randomly. At the regional and district levels, the project coordinators were interviewed. At the CHPS level, the senior-most CHO who had been at the centres since the beginning of the project at the facility was interviewed. In a situation where there was more than one senior CHO, the one in-charge of the centres was interviewed. Data was collected in the fourth year of the project implementation by trained research assistants. A structured questionnaire was used to collect the data on the demographic characteristics of the facilities, MCHNP activities being implemented, and the views of participants on barriers to MCHNP implementation. All interviews were done in English language and lasted for about 30 to 40 minutes. Prevailing processes as reviewed in the records of MCHNP implementation at the facility level were compared to the original project processes outlined in the project’s implementation guideline. Open-ended questions were used to elicit information from respondents on the barriers to the project implementation from the implementer’s perspective. The data was entered into a web-based data collection application (ODK_ona.io) and were checked for consistency and accuracy. MCHNP governance processes were determined by evidence of implementing MCHNP governance activities as outlined in the implementation guideline, an official appraisal document of the International Development Association Project. Maternal, child health, and nutrition processes were also determined by evidence of implementing MCHNP activities as outlined in the guideline. There are 8, 6, and 4 key activities expected to be implemented under Maternal, Child Health and Nutrition components, respectively. Figure 1 shows the processes that define the outcome of the MCHNP implementation status and key implementable activities according to the guideline. Tertile descriptive statistic was used to determine the status of MCHNP implementation for all components studied. The measure had three percentile cutoff points; a percentage score of <37.5% indicated “incomplete process”; scores of 37.6-75% indicated “partially completed process,” and a score of 75.1-100% indicated “fully completed process.” To obtain the score for each key activity, the number of prevailing activities for each component under implementation was divided by the total number of activities in the MCHNP implementation guidelines and then multiplied by 100 to arrive at a percentage score. Analysis was carried out using the Microsoft Excel. Barriers to the implementation of MCHNP emerged from the interviews as enumerated by respondents. This was analysed by grouping same and very similar responses into major themes that represented the barriers and presented in a word cloud. Conceptual framework showing the relationship between MCHNP processes, barriers, and outcomes. IYCE: infant and young child feeding; CMAM: community management of acute malnutrition. A conceptual framework (Figure 1) was used to illustrate the relationship between the project's processes, barriers, and implementation outcomes. Barriers at any stage of the implementation process for any of the activities may influence the implementation status, causing them to be either partially complete or incomplete. Lack of or inadequate knowledge on the project guidelines by implementers, for example, may result in nonadherence to guidelines, which may lead to some of the activities prescribed in the guidelines partially implemented or not implemented at all. Additionally, inadequate funding and lack of transport may impact negatively on supportive supervision to the peripheries. Barriers such as inadequate health personnel, lack of supplies, lack of community participation and commitment, and delays in release of funds may influence the implementation status. The study obtained approval from the Ethics Review Committee of the Research and Development Division, Ghana Health Service (ref: GHS-ERC-035/06/19). Written permissions were obtained from the Eastern Regional Health Director and the Directors of the participating districts to conduct the evaluation and publish results. Additionally, written informed consent was sought from all respondents before the data were collected.
