What Do You Do With Success? The Science of ...

1 downloads 0 Views 849KB Size Report
James F. Phillips1*. 4 ... (james[email protected]) * Corresponding author. ..... (Awoonor-Williams, Sory, Nyonator, et al., 2013a; Fajans, Simmons, &. 145.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

What Do You Do With Success? The Science of Scaling Up a Health Systems Strengthening Intervention in Ghana James F. Phillips1* John Koku Awoonor-Williams2 Ayaga A. Bawah3 Belinda Afriyie Nimako4 Nicholas Kanlisi5 Mallory C. Sheff6 Elizabeth F. Jackson7 Patrick O. Asuming8 Pearl Kyei9 Adriana Biney10 Keywords: Ghana; health system strengthening; scaling up; health policy; implementation research; embedded science; community-based primary health care; research utilization; plausibility trial; child survival

19

Abstract:

20 21 22 23 24 25

Background. The completion of an implementation research project typically signals the end of research. In contrast, Ghana has embraced a continuous process of evidence-based programming, wherein each research episode is followed by action and a new program of research to monitor and guide the utilization of lessons learned. This paper reviews the objectives and design of the most recent phase in this process, known as a National Program for Strengthening the Implementation of the Community-based Health Planning and Services (CHPS) Initiative in Ghana (CHPS+).

26 27 28 29

Description of the intervention. A process of exchanges, team interaction, and catalytic financing accelerated the expansion of community-based primary health care in Ghana’s Upper East Region. Using two Northern and two Volta Region districts the Upper East Region’s systems learning concept will be transferred to counterpart districts where a program of team-based peer training will be instituted.

30 31 32 33

Methods. A mixed method evaluation strategy has been launched involving: i) baseline and endline randomized sample survey with 247 clusters dispersed in 14 districts of the Northern and Volta Regions to assess the difference in difference effect of stepped wedge differential cluster exposure to CHPS+ activities on childhood survival, ii) a monitoring system to assess the association of changes in service system 1

Mailman School of Public Health, Columbia University, 60 Haven Avenue B-2, New York, NY 10032 ([email protected]) * Corresponding author. 2 Policy Planning Monitoring and Evaluation Division, Ghana Health Service, Private Mailbag, Accra, Ghana ([email protected]) 3 Regional Institute for Population Studies, University of Ghana, Legon, Ghana ([email protected]) 4 Policy Planning Monitoring and Evaluation Division, Ghana Health Service, Private Mailbag, Accra, Ghana ([email protected]) 5 Mailman School of Public Health, Columbia University, 60 Haven Avenue B-2, New York, NY 10032 ([email protected]) 6 Mailman School of Public Health, Columbia University, 60 Haven Avenue, New York, NY 10032 USA ([email protected]) 7 Mailman School of Public Health, Columbia University, 60 Haven Avenue, New York, NY 10032 USA ([email protected]) 8 University of Ghana School of Business, Legon, Ghana ([email protected]) 9 Regional Institute for Population Studies, University of Ghana, Legon Ghana ([email protected]) 10 Regional Institute for Population Studies, University of Ghana, Legon Ghana ([email protected]) 1

34 35 36 37

readiness with CHPS+ interventions, and iii) a program of qualitative systems appraisal to gauge stakeholder perceptions of systems problems, reactions to interventions, and perceptions of change. Integrated survey and monitoring data will permit multi-level longitudinal models of impact; longitudinal QSA data will provide data on the implementation process.

38 39 40

Discussion. CHPS+ combine mixed method research with national and regional program management to generate a system of embedded science for ensuring that results will foster a utilization process rather than a set of reform policies that must await an end-of-CHPS+ report.

41

Registration:

42 43 44 45

The National Program for Strengthening the Implementation of the Community-based Health Planning and Services (CHPS) Initiative in Ghana (CHPS+) is a forthcoming plausibility trial whereby observational units are districts of the Government of Ghana health system. The study is nevertheless in the process of undergoing registration.

46 47

BACKGROUND

48

Scientists completing work on successful experimental health systems studies often recommend

49

scaling-up results, ending research by handing over lessons learned to policy makers and managers (Chopra

50

et al. 2009). This paper presents a contrasting paradigm: researchers, policy makers and managers who have

51

completed a successful experiment will now begin a program of action and research to develop and test

52

strategies for scaling it up. This new program represents a new phase in a process of two decades of

53

implementation science for producing outcomes and actions to guide the development of community-based

54

primary health care in Ghana (Awoonor-Williams et al. 2017) .

55

Community-based Health Planning and Services (CHPS). Representing Ghana’s flagship approach

56

to achieving Universal Health Coverage, Ghana’s Community-based Health Planning and Services (CHPS)

57

was launched in 2000 to scale-up community-based primary health care strategies. These were proven by

58

an experimental study of the Navrongo Community Health and Family Planning Project to be a promising

59

mechanism for saving lives (Binka et al. 2007; Nyonator et al. 2005). A series of replication projects in

60

response to Navrongo research showed that its strategies represent an approach to basic curative and

61

preventive integrated care that improves health and reduces maternal and childhood mortality (Awoonor-

62

Williams et al. 2004; Awoonor-Williams et al. 2005; Awoonor-Williams et al. 2015).

63

While CHPS has remained a signature achievement of the Ghana Health Service (GHS), Ghana

64

has struggled to bring primary health services to all who need them, largely because leadership and support

65

systems development at the regional, district, and sub-district levels have been neglected or isolated from

66

academic and national support systems. Evidence reported by national monitoring systems in 2008 showed

67

that the pace of CHPS scale-up was progressing so slowly that targeted coverage would require nearly five

68

decades of effort if current rates of scale-up continued without reform (Nyonator, Awoonor-Williams, and

69

Phillips 2011). Moreover, evidence from field research showed that implementation had drifted from the

70

original proven package of implementation strategies (Binka et al. 2009): CHPS was failing to achieve its 2

71

full potential. National strategies for scaling up CHPS focused on policy pronouncements, workshops, and

72

leadership training, each pursued as isolated activities that lacked systems perspectives. Policies were

73

grounded in evidence, but strategies for sharing evidence were unlinked to practical demonstration of

74

implementation in the field. University programs, which could bridge leadership gaps by training health

75

specialists, were training specialists in health science rather than managers with systems development skills

76

that lead to leadership roles. This resulted in a fundamental disconnect between capacity building, policy

77

making, and evidence-generating field stations.

78

The Ghana Essential Health Intervention Programme (GEHIP). In response, the Upper East

79

Regional Health Administration (UERHA) of the Ghana Health Service, in collaboration with the Navrongo

80

Health Research Centre (NHRC) and with technical support from Columbia University’s Mailman School

81

of Public Health, launched in 2010 the Ghana Essential Health Intervention Programme (GEHIP) to

82

develop, implement, and evaluate a program of CHPS implementation reform, restructuring, and

83

organizational change (Awoonor-Williams, Bawah, et al. 2013). Located in four of Ghana’s most

84

impoverished and remote rural districts, GEHIP implemented a series of health system strengthening

85

initiatives directed at improving leadership and governance systems at all levels of the health system within

86

the district; improving data schemes for informed decision making; designing and implementing emergency

87

referral systems that catalyzed the transport of pregnant women and children to higher levels of the

88

healthcare system where services are more available; and providing catalytic funding that allowed district

89

managers to easily respond to healthcare needs that otherwise would not be addressed with vertical disease-

90

specific allocations.

91

After five years of GEHIP implementation, results demonstrated feasible and effective means of

92

accelerating the expansion of CHPS coverage in the intervention districts compared to comparison districts.

93

This expansion resulted in a 49 percent reduction in under-five mortality in treatment areas relative to levels

94

in comparison districts (Binka et al. 2007). GEHIP reduced the time to achieving CHPS-implemented

95

Universal Health Coverage from a national pace that would have required 49 years to a project pace of

96

expansion that achieved this goal in only 5 years (Figure 1). Not only was CHPS expanded, but service

97

quality was also enhanced with frontline worker retraining and the addition of emergency public health

98

capabilities (Awoonor-Williams et al. 2015).

99

Transformative interventions that enabled these achievements to be attained in five years included

100

strengthening CHPS by expanding the role of the community health nurse and volunteer in maternal,

101

newborn and child health, and improving the skills of the nurses (including midwives) and volunteers in

102

life saving interventions such as applying neonatal resuscitation, kangaroo mother care, and care for febrile

103

illnesses. Other interventions included the provision of family planning (FP) and reproductive health (RH)

104

services, training of nurses in Integrated Community Case Management (ICCM), improving the leadership 3

105

capabilities of nurses and their supervisors through training, and improving logistics supplies and

106

management.

107

Each participating district was provided with a modest commitment of supplemental funding over

108

a three year period, providing a basis for exchanges, budgeting, and community engagement to be

109

appropriately focused on CHPS start-up activities. Classroom sessions were minimized; instead, systems

110

strengthening activities were launched in conjunction with community engaged frontline worker training

111

in interventions and peer exchanges to demonstrate teamwork and practical task planning. Emergency

112

referral capacity was instituted with an approach that links worker training to community mobilization and

113

information support; perinatal interventions; and volunteer recruitment, training, and support. The outcome

114

was an approach to integrated services that expanded the coverage and quality of IMCI services and

115

responsiveness to emergency care needs. By linking grassroots politicians to community efforts, the

116

popularity of health development was demonstrated in ways that built political commitment to leveraged

117

financing of health sector investment in CHPS. Community volunteerism, catalytic resources, politically

118

inspired development investment, and sustained diplomatic support from district health officials worked as

119

a system of interaction that transformed CHPS implementation.

Figure 1:

120 121 4

122

THE CHPS+ PROGRAM

123

In keeping with Ghana’s legacy of evidence-base health system programming, the successes of

124

GEHIP are being transitioned to a replication trial phase that will develop, test, and disseminate a strategy

125

for reforming CHPS based on GEHIP successes. Its continuous functioning will provide a learning platform

126

for informing national efforts to scale-up GEHIP strategies. The Program for Strengthening the

127

Implementation of the Community-based Health Planning and Services Initiative in Ghana (CHPS+) is a

128

five year project that aims to strengthen the capacity of District Health Management Teams (DHMT) to

129

oversee improvements in the quality of primary health care, focusing in particular on family planning and

130

maternal, newborn and child health care delivery. CHPS+ is comprised of a program of applied learning,

131

team problem solving, peer mentoring, incentivizing financing for improving basic equipment

132

requirements, and technical training that strengthens Ghana’s health system at all levels. It is designed with

133

the intention of decentralizing reform of CHPS implementation activities, with GEHIP lessons learned

134

providing a guide to strategic planning and action. As such, CHPS+ represents a program of research on

135

the utilization of GEHIP research -- the science of which differs from the science of implementing and

136

evaluating a ‘proof of concept’ trial.

137

This application of implementation research is not new. Organizational change research is a well-

138

developed scientific field in business and public administration with decades of grounding in theory,

139

methods, and application (Katz & Kahn 1978; Dalton & Lawrence 1970; Lawrence & Lorsch 1969).

140

However, scientific investigation of scaling up is only rarely applied to health systems research projects in

141

Africa (Phillips, Sheff, & Boyer, 2015).

142

The CHPS+ theory of change. CHPS+ is grounded in experience with planned organizational

143

change in Ghana. Taken as a set of activities, Figure 2 portrays a model for catalyzing implementation-

144

based learning and “guided diffusion” for spreading commitment to community-engaged CHPS

145

implementation and functioning (Awoonor-Williams, Sory, Nyonator, et al., 2013a; Fajans, Simmons, &

146

Ghiron, 2006; Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004; Nyonator, Awoonor-Williams,

147

Phillips, Jones, & Miller, 2005a). The district management system is the focus of intervention, with district

148

team stakeholders constituting players in the process of instituting large scale change. To implement the

149

CHPS+ program, key elements of the GEHIP approach will be transferred to regional, district, sub-district,

150

and community-level teams through exchanges that are field based and designed to demonstrate core

151

GEHIP action agenda. Since all district implementers cannot possibly be included in a program of

152

exchange, a program of interchange and outreach is envisioned that will focus on catalytic leadership

153

implementation units that represent the authority and implementation hierarchy in participating districts

154

(DeSavigny & Adam 2009). Once GEHIP-like implementation is installed in one or two localities of

155

participating districts, the approach will have bridged the implementation knowledge gap: Training will not 5

156

just convey knowledge and ideas, but will create implementation capacity through demonstration at districts

157

of excellence where operations are fully functioning. Termed Systems Learning Districts (SLD) these

158

localities will provide the core capability of the CHPS+ learning system. At each SLD, there will be a

159

program that generates implementation experience with the effective development and functioning of

160

CHPS at the community level (left hand panel, Figure 2). Then, with functional CHPS implementation as

161

a learning platform, project resources will be directed to sponsoring exchanges within participating districts

162

so that neighboring communities participate in exchanges via jointly convened public events termed

163

durbars where grass-roots political engagement can proceed, local traditional leadership can be manifest,

164

and progress with health development can be celebrated by all.

165 166 Figure 2: The CHPS+ Theory of Change

CHPS+ System learning

National Policy Planning Monitoring & Evaluation Division Secretariat

2 CHPS+ Regions

C

Regions

Learning system utilization for policy

Policy exchanges

leadership

4 System Learning Districts

D Peer learning exchanges

B

Diffusion of implementation

A

4-6 Sub4-6 Sub4-6 Sub4-6 Subdistricts per 4-6 Subdistricts per districts per districts per district districts per district district district district

Districts Leadership leadership development

Sub-districts Diffusion of implementation

leadership

E

Communitybased demonstration

167 168 169

Implementing CHPS+: The Systems Learning Districts (SLD). GEHIP has made considerable

170

progress in creating these conditions in four of Ghana’s most impoverished districts. There is a need to 6

171

convert these districts from experimental zones into SLDs where the elements of system resilience can be

172

demonstrated for replication (Text Box 1).

173

CHPS+ will create SLDs not only as districts of excellence and innovation for the rest of the

174

districts to emulate, but also as localities where a culture of health service excellence and systems thinking

175

can be demonstrated, studied, and disseminated as a process of community-based primary health care

176

development that has been tested by GEHIP, but remains untested as a replicable strategy for scale-up. To

177

maximize capabilities to replicate GEHIP, teams from the SLD will be taken through visitation cycles, first

178

to the GEHIP intervention districts in the Upper East Region, and then to SLDs that the project will generate,

179

where they will learn about GEHIP development processes from peers who have managed and implemented

180

the program. In this manner, CHPS+ will be an experiment in the utilization of an experiment. TEXT BOX 1

What is a System Learning District? Implementation research on the early CHPS start-up era showed that workshops, policy instructions, and technical assistance had little lasting impact on the pace of national CHPS introduction. By 2008, 92% of the national CHPS coverage was located in 38 districts that had participated in exchanges organized by the Nkwanta Health Development Centre or the Navrongo Health Research Centre. Systems Learning Districts will be convened to replicate this experience, but apply systems leadership development lessons from GEHIP to the regimen of learning. SLD will conduct activities that replicate early CHPS exchanges: 

Focusing on finding “champions of change”: Invitees will be prioritized by evidence of past commitment to CHPS and ideational leadership in making CHPS work.



Team building: SLD exchanges will focus on implementation teamwork, avoiding the workshop pitfalls of selecting individuals and extracting them from their implementation teams and functions for a few days of didactic training.



Implementation-based training: Participating teams will know in advance that SLD training has resources to commit for implementing a pilot CHPS zone, but that implementation will have expectations that teams will learn about, milestones that include community, political, and development sector engagement. By teaming participants with SLD implementers, CHPS milestones will be demonstrated via a participatory process rather than through lectures and documents.



Guided diffusion outcomes: Trainees will be equipped to develop demonstration and scale-up capacity within their home districts. The goal of each SLD is to ensure that every participating district has a demonstration CHPS zone and capacity to develop demonstration sub-district. CHPS+ will foster the creation of a system of implementation that extends from doorsteps, to CHPS zones, to sub-district Health Centres, and District Health Management Teams. Systems capacity will set the stage for districtwide CHPS implementation, since pilot capacity can be translated into a participating district program of guided diffusion, whereby communities learn from communities, sub-district teams learn from counterparts, and district managers have an organized resource for accelerating CHPS implementation.



Model functionality: SLD will have model data systems with capabilities to demonstrate data capture, analysis, and use. All essential primary health care functions will be implemented with technical support from UDS/TTH and UHAS faculty. All SLD will have training capabilities, linked to regional training unis and counterpart academic units of participating universities. The GHS will ensure that demonstration zones have a full complement of staffing: community nurses, midwives, supervisors, CHPS coordinators, and fully staff District Health Management Teams.

181 182 7

183

Collaborating partners. The overall goal of the project is to develop sustainable capacity to

184

implement, monitor, and evaluate a health systems strengthening strategy in Ghana that will improve

185

national capabilities to scale-up community-based primary health care coverage, quality, and impact. This

186

approach of phased capacity building for scale-up will create a culture of health service excellence and

187

systems thinking within the GHS and demonstrate the process of community-based primary health care

188

development that has been tested by GEHIP. The project will assemble into a single system of care

189

successful health system strengthening innovations. By integrating capacity-building functions into existing

190

regional and local training institutions, in partnership with a university-based capacity-building program,

191

CHPS+ will pursue the objective of institutionalizing health systems development and build a unified and

192

sustainable Ghanaian system of community-based primary health care. CHPS+ will implement an

193

integrated management approach by bringing together institutions involved in training health professionals,

194

and individuals who have played pioneering roles in health development innovations and strengthening in

195

Ghana.

196

The implementation of CHPS+ service and systems strengthening activities will be the

197

responsibility of the Ghana Health Service Policy Planning Monitoring and Evaluation (PPME) Division.

198

This will ensure that CHPS+ builds upon a legacy of implementation expertise, yet coordinates its efforts

199

with the investments and regional programs of other donors and initiatives that must coordinate their

200

priorities and activities with the GHS, enabling the CHPS+ partnership to function more in the manner of

201

a national consortium than a project. The Regional Institute for Population Studies (RIPS) at the University

202

of Ghana will lead the research and evaluation effort for CHPS+ in the two regions. The University for

203

Development Studies (UDS) and the Tamale Teaching Hospital (TTH), as well as the University of Health

204

and Allied Sciences (UHAS), are responsible for training the next generation of health professionals in the

205

Northern and Volta regions of Ghana. Columbia University’s Mailman School of Public Health will provide

206

technical support in the areas of implementation, research, and capacity building.

207

EVALUATION DESIGN

208

Household Survey. CHPS+ will test the implementation hypothesis that the pace of expansion of

209

CHPS population coverage can be significantly increased relative to the pace of CHPS expansion in districts

210

not yet exposed to CHPS+ interventions. A three component mixed method evaluation strategy has been

211

launched for program evaluation involving : i) baseline and endline randomized cluster sample survey with

212

247clusters dispersed in 14 districts of the Northern and Volta Regions for assessing the effect of cluster

213

exposure to CHPS+ activities on childhood survival; ii) a monitoring system for assessing the association

214

of changes in service system readiness with CHPS+ interventions; and iii) a program of qualitative systems

215

appraisal (QSA) to gauge stakeholder perceptions of systems problems, reactions to CHPS+ interventions,

216

and perceptions of change. Temporal variance in project implementation will be monitored to provide 8

217

stepped wedge recorded differential exposure to operations. Integrated survey and M&E data will permit

218

multi-level longitudinal models of impact; longitudinal QSA data will provide data on the implementation

219

process.

220

Assessing Impact. CHPS+ will have core, intermediate outcome, and process endpoints, each

221

requiring systems of data capture, data management, and analysis to gauge project impact. These core

222

endpoints and indicators will be consistent with the Ghana Ministry of Health core indicators of health

223

improvement with instruments designed to maximize comparability with national Ghana Demographic and

224

Health Survey instruments. This will involve indicators of under-five mortality, infant mortality, and

225

neonatal mortality by gender of child; age specific and total fertility rates and proximate determinants that

226

are relevant to policy; and indicators of parental health seeking behavior, such as skilled attendant delivery,

227

care of sick children, exposure to community-based services, distance to health facility and utilization of

228

facilities for essential care. Critical covariates essential to the understanding of equity and impact, such as

229

educational attainment, household economic status, and distance to service point will also be assessed.

230

CHPS+ will utilize impact assessment strategies that have worked well for GEHIP. Routine

231

compilation of time trends indicators will be supplemented with end-of-project difference-in-differences

232

calculations for each indicator. This econometric strategy has been applied elsewhere for the assessment of

233

non-randomized plausibility trials (Dimick & Ryan 2014; Conley & Taber 2005; Donald & Lang 2007) and

234

successfully applied to the evaluation of GEHIP (Bawah et al. 2017) ,The procedures involves collecting

235

data in baseline clusters, monitoring systems changes and the timing of these changes, and repeating the

236

survey in baseline clusters with a separate endline stage two sample to gauge effects. Regression analysis

237

is based on merged baseline and endline data for the estimation of parameters that control for baseline

238

differences and contextual confounders, changes over time that are unrelated to interventions, and

239

conditional effects of interventions that control for these confounding changes by estimating net

240

intervention effects. A difference-in-difference estimate of program effects is given by the child survival

241

effect of CHPS+ systems interventions (s) where individual child i is scored 1 if the household is located

242

in a cluster that is exposed to CHPS treatment and zero otherwise and z is scored 1 if the case i is observed

243

in the endline and zero if the case is observed in the baseline:

244

𝑲

𝒉𝒙(𝒕) = 𝒉𝟎 (𝒕)𝒆𝜷𝑺𝒊+ 𝜸 𝒁𝒊 + 𝜹𝒁𝒊𝒋 𝑺𝒊 + ∑𝒌=𝟏 ∅𝒌 𝑿𝒊𝒌

245

(1)

246

with the vector X defining K nuisance characteristics of the child, the household where the child resides,

247

and the time independent distance of the household from hospitals and health centers in study areas. Since

248

the interventions of CHPS+ are time bound, multi-level, and complex, actual estimation of (1) will involve

249

expanding the model to a multi-level specification with time-dependent effects of S on survival. 9

250

Qualitative Systems Appraisal. CHPS+ will conduct longitudinal qualitative research on systems

251

functioning, systems changes, and project processes and implementation impact. Techniques employed,

252

will be adapted from qualitative research tools of the business and organizational research paradigm

253

developed by various authors and applied in various ways as ‘the strategic approach’ (Simmons & Shiffman

254

2007; Simmons et al. 2002; ), participatory planning (O’Reilly-de Brún et al. 2016; Leung et al. 2004),

255

organizational development (Glaser 1986; Pettigrew et al. 2001; Dalton & Lawrence 1970; Lawrence &

256

Lorsch 1969) and people-centered science (Gilson et al. 2011; Sheikh et al. 2014). In this approach, key

257

stakeholders are identified at each level of the organization, applying the concept of an open system, and

258

research is applied to gauging reactions, advice, or experience of stakeholders at each level. Open systems

259

theory emphasizes the importance of adapting formal organizational structure and functioning to the social,

260

economic, or political context in which effective functioning can be optimized (Katz & Kahn 1978). In this

261

instance, the application of open systems thinking requires any research on the functioning of CHPS to

262

focus on the social and political system at the community and district levels, not just health system of the

263

GHS. QSA must also be multi-leveled, with qualitative data compiled at the frontline worker, supervisory,

264

and managerial level to structure and define a system narrative on the operational design, functioning and

265

leadership of CHPS.

266

To monitor and interpret the impact of CHPS+ on change, teams participating in CHPS+ must be

267

the focus of QSA before their exposure to the intervention, immediately following the intervention, and at

268

the end of the project. Examples of this approach, as applied to CHPS have informed the GHS of community

269

and worker perceptions of the appropriate design of operations (Nazzar et al. 1995), social constraints to

270

particular strategies (Adongo et al. 2014; Adongo et al. 2013; Krumholz et al. 2014), worker reactions to

271

CHPS (Nyonator et al. 2008;Nyonator et al. 2005) and stakeholder advice and impressions of the impact of

272

interventions on systems change.

273

The baseline phase of the QSA will precede the intervention as it will provide the needed contextual

274

information to ensure that certain procedures are tailored to the districts for a smoother scale up. In addition

275

to this, the QSA will also explore community and health care workers’ perceptions about CHPS and

276

CHPS+, and also assess the successes and challenges of the scale up during and after implementation of the

277

interventions.

278

DISCUSSION

279

CHPS+ will be an implementation research project that develops and tests a strategy for scaling up

280

community-based primary health care in Ghana. Despite impressive investment of Government of Ghana

281

resources in manpower expansion, equipment, and community facilities, the pace of program

282

implementation is unacceptably slow. Community-engagement has been neglected, with programs for

283

facility development relying more on contractors than on community commitment to make services work. 10

284

Manpower for community services is expanding faster than the availability of facilities where workers can

285

be posted. There is a need to redirect investment into low cost and effective alternative strategies for

286

expanding CHPS operations that have been demonstrated by the GEHIP project in the Upper East Region,

287

but will remain confined to that region unless scaling up strategies are developed and tested. CHPS+ will

288

not only fill an information gap in primary health care development in Ghana, its management will be

289

integrated into national, regional, and district systems of program coordination. As such, it represents an

290

application of embedded science to the process of ensuring essential program ownership of the

291

implementation process (Ghaffar et al. 2013; Ghaffar et al. 2017). It will test a means of accelerating CHPS

292

expansion that is based on GEHIP success, but implemented with an approach that aims to demonstrate

293

large scale action with lifesaving outcomes. Taken as a system of interventions, training, and program

294

development, CHPS+ will demonstrate a practical approach to evidence-based health systems development

295

in Sub-Saharan Africa.

296 297

List of abbreviations

298

CHPS

Community-based Health Planning and Services Initiative

299

CHPS+

Program for Strengthening the Implementation of the Community-based Health Planning

300

and Services Initiative in Ghana

301

DHMT

District Health Management Teams

302

FP

Family Planning

303

GEHIP

Ghana Essential Health Intervention Program

304

GHS

Ghana Health Service

305

IMCI

Integrated Management of Childhood Illness

306

ICCM

Integrated Community Case Management

307

NHRC

Navrongo Health Research Centre

308

PPME

Policy Planning Monitoring and Evaluation Division, Ghana Health Service

309

QSA

Qualitative Systems Appraisal

310

RH

Reproductive Health

311

RIPS

Regional Institute for Population Studies

312

SLD

System Learning District

313

TTH

Tamale Teaching Hospital

314

UDS

University of Development Studies

315

UHAS

University of Health and Allied Sciences

316 317

Declarations 11

318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348

Ethics Approval and consent to participate IRB approval has been granted by the ethical review board of the Ghana Health Service under protocol number GHS-ERC 04/01/2017 and by the Research and Compliance Administration System of Columbia University under protocol number IRB-AAAR0315. Consent for publication Not applicable. Availability of data and material The National Program for Strengthening the Implementation of the Community-based Health Planning and Services (CHPS) Initiative in Ghana (CHPS+) is an ongoing protocol that is currently in the baseline data collection phase. Under agreement with parties to the project protocol and its primary donor, Columbia University will be responsible for ensuring data sharing within the CHPS+ partnership and public domain access to core data resources of the project within two years of completion of the project via an open access portal to be installed at https://dataverse.harvard.edu/dataverse/AHI. Competing Interests The authors declare that they have no competing interests. Funding CHPS+ is implemented with support provided by a grant to Columbia University’s Mailman School of Public Health by the Doris Duke Charitable Foundations (Grant # 2016107). Author’s contributions The CHPS+ initiative was designed by JFP, JKA, and AAB and its protocol was developed by JFP in collaboration with JKA, AAB, and MCS. The manuscript was adapted from the protocol by MCS with sections on implementation revised by JFP, JKA, NK, and BAN. Research and evaluation methods sections were reviewed and revised by JFP, AAB, AB, EFJ, POA, and PK. Acknowledgements:

349 350 351 352 353 354 355 356 357

Preparation of this article was supported by grants of the Doris Duke Charitable Foundation’s (DDCF) African Health Initiative to the Mailman School of Public Health, Columbia University. The authors gratefully acknowledge advisory support of members of the DDCF African Health Advisory Council Members and guidance of the Ghana Health Service CHPS+ Strategic Advisory Committee chaired by Dr. Ebenezer Appiah-Denkyira, MB.ChB, MPH.

358 359 360 361

Adongo, P.B. et al., 2014. “If you do vasectomy and come back here weak, I will divorce you”: a qualitative study of community perceptions about vasectomy in Southern Ghana. BMC international health and human rights, 14(1), p.16. Available at: http://www.biomedcentral.com/1472-698X/14/16 [Accessed August 5, 2014].

362 363 364 365

Adongo, P.B. et al., 2013. The role of the Community-based Health Planning and Services Strategy in involving males in the provision of family planning services: A qualitative study in southern Ghana. Reproductive Health, 10(36), pp.10–36. Available at: http://www.reproductive-healthjournal.com/content/10/1/36. [Accessed April 18, 2014].

366

Awoonor-Williams, J.K. et al., 2004. Bridging the gap between evidence-based innovation and national

References

12

367 368

health-sector reform in Ghana. Studies in family planning, 35(3), pp.161–77. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15511060 [Accessed November 1, 2016].

369 370 371

Awoonor-Williams, J.K. et al., 2005. Ghana Health Service. 2005. Community Health Planning and Services (CHPS): The Operational Policy. Ghana Health Service Policy Document No. 20. Accra: Ghana Health Service (unpublished). 1. , (20).

372 373 374 375

Awoonor-Williams, J.K., Sory, E.K., et al., 2013. Lessons learned from scaling up a community-based health program in the Upper East Region of northern Ghana. Global Health: Science and Practice, 1(1), pp.117–133. Available at: http://www.ghspjournal.org/cgi/doi/10.9745/GHSP-D-12-00012 [Accessed May 31, 2015].

376 377 378 379 380

Awoonor-Williams, J.K., Bawah, A.A., et al., 2013. The Ghana essential health interventions program: a plausibility trial of the impact of health systems strengthening on maternal & child survival. BMC Health Services Research, 13(Suppl 2), p.S3. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3668206&tool=pmcentrez&rendertype=abstr act [Accessed June 5, 2013].

381 382 383

Awoonor-Williams, J.K., Phillips, J.F. & Bawah, A.A., 2015. Catalysing the Scale-Up of CommunityBased Primary Health Care in a Rural Impoverished Region of Northern Ghana. International Journal of Health Planning and Management.

384 385 386

Awoonor-Williams, J.K., Phillips, J.F. & Bawah, A.A., 2017. The application of embedded Implementation science to developing community-based primary health care in Ghana. Learning Health Systems.

387 388 389

Bawah, A.A. et al., 2017. The child survival impact of the Ghana Essential Health Interventions Program: A health systems strengthening initiative in a rural region of northern Ghana. In Annual Meeting of the Population Association of America. Chicago, Illinois.

390 391

Binka, F.N. et al., 2009. In-depth review of the Community-Based Health Planning Services (CHPS) Programme A report of the Annual Health Sector Review, 2009, Accra, Ghana.

392 393 394

Binka, F.N. et al., 2007. Rapid achievement of the child survival millennium development goal: evidence from the Navrongo experiment in Northern Ghana. Tropical medicine international health TM IH, 12(5), pp.578–583. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17445125 [Accessed August 23, 2013].

395 396 397

Chopra, M. et al., 2009. Achieving the health Millennium Development Goals for South Africa: challenges and priorities. Lancet, 374(9694), pp.1023–31. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19709737 [Accessed January 29, 2014].

398 399

Conley, T. & Taber, C., 2005. Inference with “Difference in Differences” with a Small Number of Policy Changes. Available at: http://www.nber.org/papers/t0312 [Accessed January 27, 2016].

400 401

Dalton, G.W. & Lawrence, P.R., 1970. Organizational Change and Development. G. W. Dalton & P. R. Lawrence, eds., Burr Ridge, Illinois: Richard D. Irwin, Inc.

402 403

DeSavigny, D. & Adam, T., 2009. Systems Thinking for Health Systems Strengthening, Geneva: Alliance for Health Policy and Systems Research, World Health Organization.

404 405

Dimick, J.B. & Ryan, A.M., 2014. Methods for evaluating changes in health care policy: The differencein-differences approach. Journal of the American Medical Association, 312(22), pp.2401–2402.

406 407

Donald, S.G. & Lang, K., 2007. Inference with Difference-in-Differences and Other Panel Data. Review of Economics and Statistics, 89(2), pp.221–233.

408 409 410

Fajans, P., Simmons, R. & Ghiron, L., 2006. Helping public sector health systems innovate: the strategic approach to strengthening reproductive health policies and programs. American Journal of Public Health, 96(3), pp.435–40. 13

411 412 413

Ghaffar, A. et al., 2013. Changing mindsets in health policy and systems research. Lancet, 381(9865), pp.436–7. Available at: http://www.thelancet.com/journals/a/article/PIIS0140-6736%2812%29618583/fulltext [Accessed July 27, 2014].

414 415

Ghaffar, A. et al., 2017. Strengthening health systems through embedded research. Bulletin of the World Health Organization,, 95, p.87.

416 417

Gilson, L. et al., 2011. Building the Field of Health Policy and Systems Research: Social Science Matters. PLoS Med, 8(8), p.e1001079.

418 419 420

Glaser, E.M., 1986. Planned Organizational Change: Factors Bearing Upon Sturdy Versus Fragile Rooting. Science Communication, 8(2), pp.260–269. Available at: http://scx.sagepub.com/content/8/2/260.short [Accessed December 2, 2015].

421 422

Greenhalgh, T. et al., 2004. Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations. Milbank Quarterly, 82(4), pp.581–629.

423 424

Katz, D. & Kahn, R.L., 1978. The Social Psychology of Organizations Second., Hoboken, New Jersey: John Wiley and Sons.

425 426 427 428

Krumholz, A.R. et al., 2014. Factors facilitating and constraining the scaling up of an evidence-based strategy of community-based primary care: Management perspectives from northern Ghana. Global public health, pp.1–13. Available at: http://dx.doi.org/10.1080/17441692.2014.981831 [Accessed December 5, 2014].

429 430

Lawrence, P.R. & Lorsch, J.W., 1969. Developing Organizations: Diagnosis and Action., Reading, Massachusetts: Addison-Wesley, Inc.

431 432 433

Leung, M.W., Yen, I.H. & Minkler, M., 2004. Community based participatory research: a promising approach for increasing epidemiology’s relevance in the 21st century. International Journal of Epidemiology, 33, pp.499–506.

434 435

Nazzar, A. et al., 1995. Developing a culturally appropriate family planning program for the Navrongo experiment. Studies in Family Planning, 26, pp.307–324.

436 437 438 439

Nyonator, F.K. et al., 2008. “Scaling up experimental project success with the Community-based Health Planning and Services Initiative in Ghana. In R. Simmons, P. Fajans, & L. Ghiron, eds. Scaling Up Health Service Delivery: From pilot innovations to policies and programmes. Geneva: World Health Organization, pp. 89–112.

440 441 442 443

Nyonator, F.K. et al., 2005. Guiding the Ghana Community-Based Health Planning and Services Approach To Scaling Up With Qualitative Systems Appraisal. The International Quarterly of Community Health Education, 23(3), pp.189–213. Available at: http://baywood.metapress.com/openurl.asp?genre=article&id=doi:10.2190/NGM3-FYDT-5827-ML1P.

444 445 446

Nyonator, F.K., Awoonor-Williams, J.K. & Phillips, J.F., 2011. Scaling Down to Scale-up: Accelerating the Expansion of Coverage of Community-based Health Services in Ghana. In Dakar, Senegal: International Family Planning Conference, Dakar Senegal.

447 448 449

Nyonator, F.K.F. et al., 2005. The Ghana community-based health planning and services initiative for scaling up service delivery innovation. Health policy and planning, 20(1), pp.25–34. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15689427 [Accessed March 19, 2012].

450 451 452 453

O’Reilly-de Brún, M. et al., 2016. Using Participatory Learning & Action research to access and engage with “hard to reach” migrants in primary healthcare research. BMC health services research, 16(1), p.25. Available at: http://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-015-1247-8 [Accessed January 23, 2016].

454

Pettigrew, A.M., Woodman, R.W. & Cameron, K.S., 2001. Studying Organizational Change And 14

455 456

Development: Challenges For Future Research. Academy of Management Journal, 44(4), pp.697–713. Available at: http://amj.aom.org/content/44/4/697.full [Accessed August 6, 2014].

457 458 459

Phillips, J.F., Sheff, M.C. & Boyer, C.B., 2015. The astronomy of Africa’s health systems literature during the MDG era: where are the systems clusters? Global Health: Science and Practice, 3(3), pp.482– 502.

460 461 462 463

Sheikh, K., George, A. & Gilson, L., 2014. People-centred science: strengthening the practice of health policy and systems research: Health Research Policy and Systems. Health research policy and systems, 12–19(1), p.19. Available at: http://health-policy-systems.biomedcentral.com/articles/10.1186/14784505-12-19 [Accessed October 27, 2016].

464 465

Simmons, R., Brown, J. & Díaz, M., 2002. Facilitating large-scale transitions to quality of care: an idea whose time has come. Studies in Family Planning, 33, pp.61–75.

466 467 468 469

Simmons, R. & Shiffman, J., 2007. Scaling-up reproductive health service innovations: A conceptual framework. In R. Simmons, P. Fajans, & L. Ghiron, eds. Scaling Up Health Service Delivery: From pilot innovations to policies and programmes. Geneva: World Health Organization. Available at: http://www.expandnet.net.

470

15