Community Based providers for Maternal and Neonatal Health

1. Community Based providers for Maternal and Neonatal Health GHANA

2. Outline of presentation • Background. • Arrangements for Community Service delivery • Types of Community Based providers of MNH currently in country:, names and scopes of practice and positioning in health system • Organization(s) employing or supporting community based providers • Policies on the roles and tasks (e.g. education, referral, provision of services) of community based providers (auxiliary nurses and midwives., CHWs/TBAs/peer educators) related to the continuum of care for MNH services • Actual practices of Community Based Providers

3. Outline of presentation • Requirements in terms of knowledge, skills, attitudes • Performance, motivation and factors influencing performance and motivation, e.g. incentives, career perspectives • Support provided e.g. finances, technical support, training, supervision, nature of the link to health or other facilities, • Accessibility and coverage of care, • Communication and reporting • Accountability • Results of what works and why, • Challenges and lessons learned • Political, social, scientific and ideological influences on policies, practices and outcomes • Questions/issues for discussion/ research needs

4. Introduction Ghana, West Africa Population : 24,223,431 (2010 –GSS) Life expectancy at birth (2008) -Total population years-62 There are 170 (218) Districts -Male 60 years -Female 64 years Infant and under five mortality (per 1000 LB) -Infant mortality rate (2008- DHS) 50 -Under five mortality rate (2008-DHS) 80

5. Organization of District Health Services in Ghana Ghana Health Delivery System

6. Types of Community Based Providers • Skilled Providers: - Midwives, Nurses - Community Health Nurses (CHN) - Community Health Officers (CHO) • Trained Providers: - Traditional Birth Attendants - Community-Based agents(mother-support groups/mothers’ clubs, distributers, surveillance etc.) - Health Aids - Health Extension workers

7. Organizations Supporting Community Service Providers • Ghana Health Service • UNICEF • USAID • World Vision • World Bank • Oxfam • Plan Ghana • Ghana Red Cross

8. Policies Stating Roles And Tasks • Community Based Health Planning and Service (CHPS) Policy • Reproductive Health Policy • Child Health Policy • Guidelines on home-based care for malaria, diarrhoea, acute respiratory infections

9. Roles and Tasks • Health promotion activities • Mobilizing communities for health activities • Growth promotion (weighing, counseling and referral) • Assisting with NIDs • Accompanying referrals to the health facility • Breastfeeding mother support • Management of common ailments • Vital events registration • Surveillance

10. Actual practices of Community Based Providers • Trained Birth Attendants practice according to policy. Issues of prompt referrals • Community Based volunteers- generally practice according to policy. Few miscreants • Mother support groups generally perform role of supporting young mothers to exclusively breastfeed their babies- May perform other social functions.

11. Requirements: Knowledge, Skills, Attitudes - I Skilled Providers (CHOs) • Basic Training for nursing, midwifery etc. Plus • In-service training using locally developed manuals covering technical areas, community entry/mobilization etc.

12. Requirements: Knowledge, Skills, Attitudes - II Trained Providers • Policy is that they are selected through community processes. • They are trained according to standard modules developed by the GHS and/or organizations using them.

13. Factors Affecting Performance • Community acceptance • Technical supervision- maintaining contacts with them on a regular basis gives them credibility in the community. • Refresher courses/ update of knowledge and skills. • Motivation- T-shirts, bicycles, certificates, monthly/quarterly meetings • Uninterrupted supply of commodities for service delivery • Recognition by health staff and involvement in health programmes

14. Support provided • Training and refreshers • Supervision • Provision of working tools and supplies • Providing links to the Health Facilities • Means of transport – bicycles, motor bikes • Accommodation for CHO’s • Career progression for CHO’s- Can train as midwives or mental health nurses

15. Accessibility and coverage of care, Skilled Providers CHPS Coverage. There are 1,659 functional CHPS zones (39.4% of demarcated CHPS zones covering 23% of the total population. 5.2% of total outpatient care was delivered through CHPS) Trained Providers • Trained Birth Attendants and Mother support groups found all over the country- TBAs contributed 14.5% to of total deliveries captured by the health sector in 2012 • Community Based Volunteers assisting in registering newborns, immunization and referral of sick newborns- Predominantly found in the ( Four regions- UWR, UER, NR and BAR) • Mostly limited to areas with partner support

16. Communication and reporting • The Trained Traditional Birth attendants report through the nearest health facility within the sub-district they are working in. • The mother support groups and the community volunteers also report through the same system. • At the District Health Directorate level there are usually focal persons who see to the collation of reports and communication of community service delivery achievements to the rest of the District Teams. • District Annual reports and District review reports often report on community service delivery activities.

17. Accountability • The community service providers are accountable both to the community leadership that selected them with regards to performing their assigned tasks. • Technically and programmatically they are accountable to the health service or the health organization that recruited them • They account for the logistics and supplies that they receive to the health directorate • Also for activities undertaken

18. Results of what works • In regions like Upper East where CHPS and Community IMNCI have been rolled out extensively there have been consistent reductions in child Mortality - 1998-156/1000LB - 2003-79/1000 LB - 2008- 57/1000LB

19. Challenges • High attrition rate of both skilled and trained community workers • Providing sustainable motivation • Providing supportive supervision • Maintaining synergy among different implementing partners - Varying packages for motivation - Tools and training packages - Data capture • The effect of other interventions(e.g. Health Insurance)

20. Lessons learned • The need to involve the communities in the selection of the community based service providers. • Need to provide structured training for those selected. • Need to maintain continuous contact with the community based providers through supervisions and meetings. • Providing appropriate sustainable incentives

21. Political, Social, Scientific & Ideological Influences on Policies, Practices & Outcomes - I • Thought that community based providers are not what the deprived rural communities need- Equity and ethical concerns have been raised • Why provide health facilities for urban areas and community based services for rural poor? Unresolved ideological debate among senior health managers in Ghana • CBA’s function better in more rural, under-served areas

22. Political, Social, Scientific & Ideological Influences on Policies, Practices & Outcomes - II • Selection of CBA’s may be influenced by social considerations, sometimes placing square pegs in round holes • Volunteers in many instances hopeful of future change in terms of engagement

23. Questions/issues for discussion/ research needs • How do you use community based workers in deprived urban communities? • Is volunteerism still a viable option for health care delivery?

24. A CHO and a health committee discuss ways of improving health in the community.