Using a Standards-based Approach to Improve Access to Quality Primary Health Care in Western Ghana ! Chantelle Allen! 19 May 2013 !

Funded by:

Presentation Overview!
Ghana ! STAR CHPS Project ! Standards-based Management and Recognition (SBMR) ! Application of SBMR! Results and Lessons Learned !

Ghana !
Lower-middle income country ! 24+ million population! National Health Insurance ! Focus on Primary Health Care ! Health indicators: !
Maternal mortality 350 / 100,000 ! Under-5 mortality 74 / 1,000! Infant mortality 45 / 1,000! Neonatal mortality 28 / 1,000! Modern Contraceptive
References:, Demographic Household Survey 2008, WHO 2010, Multiple Indicator Cluster Survey 2012

prevalence rate 23%!

Supportive Technical Assistance to Revitalize Community-based Health Planning and Services (STAR CHPS) Project !
Increased access to quality basic primary health care! Social investment project, Jubilee Partners ! 61 Community-based Health Planning and Services (CHPS Zones) ! 6 Coastal Districts, Western Region ! 2011 2016!

Greater Access to Quality Primary Health Care !

Community engagement in health! Improved quality of service delivery at 61 CHPS zones !

Increased access to quality basic primary health care in 6 costal districts in the Western Region !

CHPS: Providing access to Primary Health Care for households and communities !
CHPS Team Members
Community Health Nurse / Officer: clinical services, management, reporting, home visits, community outreach, train volunteers

Management
Regional Health Director / Directorate: management, policy guidance District Health Management Team: Management, supervision, logistics, HR, commodities, training

Space / Place
CHPS Zone: Geographic area (# of communities) to receive services

Community Health Committee: support the community health nurse, manage community investment manage volunteers

Community Health Volunteers: home visits, support outreach, referral, home based care of malaria

Project Support Committee: advice, leverage resources, advocacy

CHPS compound: Physical space that community health nurse operates from

Quality of Health Care, a local priority !

Improving the quality of health care will save lives since people will be healthier. This would also reduce the pressure on our health facilities and the Government too can save a lot of money.!
Charlotte Danquah, District Director of Health Services, Jomoro District !

Standards Based Management and Recognition (SBMR) !

Practical management approach! Operational performance standards ! Focus on measurement and feedback! http://pdf.usaid.gov/pdf_docs/ PNADF143.pdf!

The missing puzzle pieces; expectations and performance!

Expectations
dene what is expected!

Performance
measure what is done!

Performance and Quality!

Measurement is the rst step that leads to control and eventually to improvement. If you cant measure something, you cant understand it. If you cant understand it, you cant control it. If you cant control it, you cant improve it.!
H. James Harrington !

Keeping it simple: Clarify expectations, Provide Support, Measure performance, Celebrate success !
Recognize and celebrate 4. progress (based on Celebrate results)

1. Dene!

Clearly define expectations (standards) and current performance and practice (baseline)

Measure progress of achieving standards (compare to baseline)

3. Measure!

2. Support!

Develop action plan to address gaps in expected performance and provide support to achieve the expected standards

Step 1: Dene Standards and Performance!

Operational policy for CHPS includes EPI as a focus area

National EPI schedule of Immunizations and key activities required Roles, responsibilities and services to be provided by Community Health Nurses at CHPS Records to be kept at CHPS level

Job description of CHO includes EPI actions

CHO training on EPI training, knowledge and skills

Baseline Assessment: Performance of 18 CHPS in Immunization, December 2011 !

% of Standards Achieved

100%! 80%! 60%! 40%! 20%! 0%!

100%! 80%! 60%! 40%! 20%! 20%! 0%! 0%! 0%! 80%!

100%!

60%! 60%!

60%! 60%! 60%!

20%!

20%!

Step 2: Support Performance, develop joint priorities !

Gap / Cause ! Poor immunization practices including poor storage (refrigerator not working), poor administration and no use and display of EPI data ! Intervention / Action ! 1) Training for staff on EPI and Data Management and Use! 2) Repair refrigerator ! Responsible ! Staff to submit requisition for refrigerator repair ! ! District Health Management Team to coordinate EPI training and to repair refrigerator! Support ! STAR CHPS Project will support training of Community Health Nurses ! Deadline ! Requisition for repair by ! 20 December 2011! ! EPI training by ! 15 March 2012 !

Supporting Performance!
Training and capacity building ! Monitoring and Supportive Supervision ! Champions / peer support ! Management participation in assessments and action planning ! Presentation and discussion of results with management !

Step 3: Measure Progress!

Joint assessment exercise ! Direct assessment of services ! Case studies and demonstrations ! Assessment checklists ! Immediate feedback to service providers ! Annual assessment cycle !

Summary of 18 CHPS Performance by Thematic Area, Baseline Assessment December 2011 and Follow up Assessment December 2012!
Clinical Services
Baseline, December 2012!

% Standards Achieved

100%! 80%! 60%! 40%! 20%! 0%!

87%! 59%!

85%! 50%!

82%! 45%!

83%! 58%!

82%! 62%!

75%!

77%!

24%!

24%!

Child Health! Reproductive Health!

Illnesses & emergencies!

Community linkages & outreach!

Management, services, activities & logistics !

Community Health Volunteers!

Community Health Committee!

18 CHPS Performance in Child Health, Baseline Assessment December 2011 and Follow up Assessment December 2012!
% Standards Achieved

100%! 80%! 60%! 40%! 20%! 0%!

89%!

99%! 96%! 94%! 94%! 97%! 94%! 99%! 94%! 93%! 91%! 89%!
76%! 63%! 50%! 64%! 42%! 43%! 64%!

83%! 65%!
57%!

90%! 93%! 91%!

72%!

59%! 55%! 52% 55%! !

57%!

56%! 41%! 33%!

0!

0!

Baseline, December 2011!

Follow up, December 2012!

Summary of 6 District Health Management Teams Performance!

100%! 80%! 60%! 40%! 20%! 0%!
Ahanta West! Ellembelle! Jomoro! Nzema East! SHAMA! STMA!
44%! 77%! 63%! 45%! 37%! 44%! 49%! 91%! 81%! 80%! 80%! 76%!

Baseline, December 2011!

Follow up, December 2012!

Improving quality, Improving access !

Total OPD Attendance in 18 CHPS Zones!
16000!

Total number of OPD clients

14000! 12000! 10000! 8000! 6000! 4000! 2000! 0! Q1! Q2! Q3! Q4! Q1!
All Ages!

Q2!

Q3!

2011/12

Children < 5!

2012/13

Increasing access to malaria care!

Number of malaria cases in 18 CHPS Zones! Total number of malaria cases
10000! 9000! 8000! 7000! 6000! 5000! 4000! 3000! 2000! 1000! 0!
Q1! Q2! Q3! Q4! Q1! Q2! Q3!

Conrmed!

Treated!

2011/12

2012/13

Limitations and Challenges!

Total number of new family planning acceptors
1600! 1400! 1200! 1000! 800! 600! 400! 200! 0! Q1! Q2! Q3! Q4! Q1! Q2! Q3!

Number of New Family Planning Acceptors in 18 CHPS Zones! !

2011/12
Acceptors!

2012/13

Step 4: Celebrate!
Based on results ! Certicates, awards! Media participation! Management teams ! Best practices !

Lessons Learned!
Participation: active engagement of management ! Clarication: expectations and standardization of practices! Measurement: Power of numbers (%) to communicate and advocate for change! Support and recognition: key motivators for service providers !

Has the quality of health care improved? !

There has been improvement in competencies and skills of health care services providers offer, since they now follow procedures systematically to perform their tasks. They are also aware of being monitored for good performances which at the end they will be recognised and rewarded.!
Charlotte Danquah, District Director of Health Services, Jomoro District !

!
we now know how to do things the right way and also what is expected of us. This has made a big difference.!
Martha Aggrey, Community Health Ofcer, Jomoro District !