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The President's CHPS By Anthony Gingong   
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Early this year, I remember welcoming my son from school as usual. This time, instead of our usual salutations and exchange of pleasantries, which I enjoy so much as a father, he hit me with a question: “Is it true that the President and his Ministers will provide Ghanaians with chips every month? My teacher said it in class this morning.”

Though, I wondered how the teacher would say so, I kept my cool whilst on a mental pilgrimage to find the source of this information or perhaps, this misinformation, because I knew something was amiss. I sat down to figure out what the teacher or President might have said because I knew my boy would be back for an answer.

Fortunately for me, I was saved by the 7pm news on GTV. There, I heard the President in his State of the Nation address promising to continue with the construction of more CHPS (pronounced chips) compounds. Now more confident as a ‘knowledgeable’ father, I called the little boy and said “your teacher did not mean the chips mom has been making for you, but rather Community-based Health Planning and Services which is abbreviated and called (CHPS).”

With continuous cognitive functioning of my mental faculties I recalled the 6th to 12th September, 1978 Alma Ata conference declaration of ‘Health for All’ which led to Ghana’s Ministry of Health (MoH) developing and implementing various policy interventions with emphasis on primary health care.

Some notable primary health care interventions included the training of traditional birth attendants (TBAs) to reduce maternal mortality, Expanded Programme on Immunization (EPI) which have resulted in a downtrend in childhood morbidity, and mortality.

Known epidemics such as measles, poliomyelitis, whooping cough or pertussis, diphtheria, yellow fever have become rare, whilst cerebro-spinal meningitis (CSM) caused by meningococcus bacteria has been immensely contained with limited intermittent outbreaks and incidences around the northern savanna belt stretching from Bunkpurugu, Nankpaduri, Gambaga, Sawla, Tuna, and Kalba.

The concept of home visits improved immunization coverage, increased bonding between health personnel and communities, improved personal hygiene thereby reducing the prevalence of water borne, and water related sickness such as scabies, yaws, trachoma and diarrhea. It brought about a reduction in home accidents, and the introduction of home-based care for illnesses such as malaria, fever, diarrhoea, vomiting, wound management and many more.

In 1998, Ghana’s Ministry of Health with its main service provider, the Ghana Health Service initiated a design to improve access, quality, equity, efficiency of primary health care. This followed research findings from the Navrongo Health Research Centre on an initiative known as Community-based Health Planning and Services (CHPS).

The concept looked at door-step service delivery points with local level partnership where community leaders among others contribute to making decisions on their health and its related issues.

CHPS AND MDGS 4, 5, & 6
The role of Community Health Planning and Services (CHPS) compounds is critical in primary health care delivery as well as contributing to the achievement of Millennium Development Goals 4, 5, and 6. Goal 4 will be achieved through increased coverage in immunisation, early detection of ailments and congenital abnormalities.

Health education and promotion especially on nutrition that ensures the health, growth, and development of children and thus prevent early death in children, is an important part of this concept. With health officers at the community level permanently, antenatal, and post natal care will be provided to expectant women, and mothers.

When trained health staff are in the community, there will be early detection of danger signs in pregnancy, proper referral to the appropriate facilities as well as continuous monitoring of pregnancy and its associated conditions leading to a decline in maternal mortality as challenged by Goal 5. MDG 6 looks at combating HIV/AIDS, malaria, and other diseases. This requires a well-informed health person who understands the world view of the community to develop messages and approaches in consonance with the people’s way of life to ensure acceptability.

Healthy habits such as safe sex, use of insecticide nets, basic hygienic practices will be facilitated by the Community Health Officer (CHO).

The CHPS concept is one single policy of the MOH that has facilitated geographical access to healthcare in
many communities in the Ghana. Since 1998, the health delivery system has suffered reduction in budgetary allocation but increased performance. Some of the indicators that have seen remarkable
improvement include but not limited to EPI, family planning uptake, supervise delivery, out-patient attendance, childhood nutrition and iodated salt intake.

Currently we are battling with which direction to move with CHPS the concept. The ambiguity lies in the concept of CHPS. Whilst some think that the CHPS concept was primarily for public health activities at the community level including health education and promotion through home visits, immunisation, and antenatal services, others think that CHPS has come to fill a huge gap of geographical inaccessibility to
healthcare by the deprived communities.

I support both because in most situations the Enrolled Nurse or
Community Health Nurse is the only skilled person within a 40 km radius. If she does not provide the clinical services then quacks to will do it, and we all know the results of quacks providing clinical services.

Between the TBA and the Community Health Nurse (CHN) who will understand and appreciate danger signs in pregnancy, I definitely think the CHN is better positioned. But we also need to do enough
preventive health services in the community.

A report of preventive case to the health care facility is an
indication of failure in preventive activity.

Improving CHPS
We are grateful the CHPS concept has received attention at the highest level of governance in this country. We will count on the President and the managers of health to actualize the support so we can ensure that the gulf in geographical access is bridged.

We count on the managers of health to facilitate community support in any area that has been earmarked as a CHPS zone. We can get the community to support in providing accommodation whilst the GHS provides the equipment and staffing.

The staff we assign to manage the CHPS need orientation in community management as well as some more training to handle some of the conditions that the general training fails to equip them with. For example, staff at the CHPS should be given further training in management of emergencies such as labour, convulsion, as well as bleeding since they turn to be the only hope of the communities in such emergency situations.

Appropriate transport arrangement is key to the success of CHPS. We need tricycles to serve as ambulances for easy transport of emergencies to referral points.

We need to review and incorporate community-based surveillance (CBS) into the running of CHPS as part of the communities’ contribution to health care delivery. With CBS, the CHOs have up to date data on deliveries, disease surveillance, deaths, and any unusual event occurring in their catchment areas.

A typical example of the usefulness of the CBS concept is the eradication of guinea worm disease; the story of Guinea worm will be told later.

The timely release of resources including medical consumables will boost service delivery. It is sometimes worrying when a CHO runs out of basic medications and vaccines. Also disappointing is the failure to repair the motorbikes and provide fuel for the CHPS compound.

CHPS and NHIS Capitation
Just like all healthcare facilities accredited by the NHIS, money from the Scheme has become the main source of revenue, and given the fact that CHPS compounds are present in almost all districts and communities and a lot of their activities centre on public health and primary healthcare functions, it is imperative to consider the role CHPS will play in Capitation, since this is also Primary Healthcare –based.

Capitation is a provider payment method under which an advance of a pre-determined fixed rate is paid to healthcare providers to provide a defined set of services for each individual enrolled with the Preferred Primary Provider (PPP) for a fixed period of time. The Preferred Primary-care Provider (PPP) is selected/chosen by the subscriber as his/her preferred facility. This is the health facility a subscriber chooses to receive medical treatment anytime he/she is not well.

Under this system, subscriber will be encouraged to visit the NHIS district office to select a PPP, however, failure to do so within a certain period of time given by the NHIA will imply that the Scheme will assign the subscriber to an available primary-care provider (PPP) close to the subscriber’s place of residence.

Since Capitation certainly appears as the way forward for the NHIS and Ghana’s aspiration to attain Universal Health Coverage and the fact that CHPS are an important part of the health systems of our country, I wish to spend a few paragraphs on how CHPS and capitation can interplay to ensure desired results.

Capitation payment method the world over is seen as the most efficient way of health care financing that guarantees sustainability especially in the practice of social health insurance moving towards the achievement of Universal Health Coverage.

In Ghana, the original Primary Health care (PHC) structure positioned health centers as the basic or the start-point of clinical care, it was defined as level A. However, with the inception of CHPS, this arrangement has called for a useful relook. This is because CHPS zones and compounds are to provide basic primary health care and not just primary care.

The provision of primary health care has the following components; education for the identification, prevention, and control of prevailing health challenges, proper food supplies and nutrition, adequate supply of safe water and basic sanitation, maternal and child care, including family planning, immunization against the major infectious diseases, prevention and control of locally endemic diseases, correct treatment of common diseases using appropriate technology, promotion of mental, emotional and spiritual health, and finally provision of essential drugs.

The treatment of common diseases using appropriate technology, as well as provision of essential medicines clearly suggest that if CHPS is the foundation for Primary Health care, then they it must be considered in running health insurance.

Since the developments of treatment protocols, definition of appropriate technology, and establishment of essential medicines list are all functions of the Ministry of Health, which has rightly identified the CHPS as the basic PHC delivery point. There will therefore be dissonance if CHPS are left out of capitation which deals with primary care cases or diseases.

When CHPS compounds with trained health care personnel such as Enrolled Nurses (EN), Community Health Nurses, and or midwives are handling the OPD cases, it automatically provides a gatekeeper system where screening and treatment of minor conditions take place whilst the more serious and difficult cases are referred to higher levels.

The author is the Director of Quality Assurance at the National Health Insurance Authority.
Source: Peacefmonline.com

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