Performance of Community Health Workers in the Community Health Worker Programme in Upper Manya Krobo Distrct of Ghana: Role of Health Sector and Community

ABSTRACT

Background: The Alma-Ata declaration of 1978 promoted broader use of Community Health Workers (CHWs) to provide certain interventions and promote health behaviours at the community level. The Government of Ghana in 2016 launched the new Community Health Worker Program (CHWP). This was followed by recruitment, training and deployment of 20000 CHW to Community-based Health Planning and Services (CHPS) zones. Since the programme inception, the performance of CHWs and the possibility of implementing and sustaining large-scale CHW programmes have been a source of worry.

Objective: The research aimed at identifying the determinants influencing the performance of CHWs in Upper Manya Krobo District.

Methods: A descriptive cross-sectional survey using both quantitative and qualitative data collection methods were used. Purposive sampling method was used to identify the respondents. Quantitative data was collected from 45 CHWs while qualitative data was collected from 4 District Health Management Team (DHMT) members, a Regional CHPS Coordinator, a District Youth and Employment Agency (YEA) Coordinator and 25 Supervisors of CHWs and Community Health Committee leaders. Data was presented using tables, graphs and cross tabulation while inferential statistics were computed using odds ratio. The organizing themes from the qualitative data were analyzed using the thematic analysis approach as described by Attride-Stirling (2001). The coding of transcripts was guided by the initial list of organizing themes (deductive) which were modified and expanded based on information derived from reading the transcripts (inductive). After all the transcripts had been coded, there was a review of the generated codes. This was to ensure consistency in coding. The next stage of the analysis involved a more nuanced linkage of codes. This led to codes being assigned to the appropriate organizing themes. Representative quotes that best capture the ideas are presented for illustration.

Findings: Among all the demographic factors, it is only main source of income (OR: 16.111, CI: 1.160-223.800 p=0.038) that was statistically significant in relation to the performance. Gender (OR: 1.06, CI: 0.190-16.040 p=0.947) was not statistically significant in relation to the CHW performance, when adjusted for males, females had 1.3 odds of performing health care services compared to males (AOR: 1.337, CI: 0.115-16.428, p=0.800). Majority of respondents 27(87%) said CHW functionality, start up and program management processes were never done with very few 4(13%) who acknowledged it was done sometimes, representing low fidelity. Performance of CHWs was very poor. On average the overall rate of CHWs with good performance at the CHPS zone was 5(11%). The adequacy of training was also not statistically significant (OR: 0.869, CI: 0.153-4.928 p=0.874) to performance. Scheduled individual supportive supervision visits for the CHWs; one time (OR: 2.231, CI: 0.193–25.721 p=0.520) to more than three times (OR: 0.935, CI: 0.087-10.045 p=0.956) in general had no statistical significance to CHWs performance. Monthly meetings to discuss challenges and solutions (OR: 1.473, CI: 0.208-10.448 p=0.699) does not have effect on CHWs performance. Remuneration such as cash payment (OR: 27.0, CI: 0.952-766.122 p=0.053) generally showed no statistical significance to performance. However, majority 40 (91%) said the allowance they received is inadequate. There was no statistical significance with feedback reports (OR: 0.886, CI: 0.101-7.762 p=0.084). However, the use of information for planning and addressing gaps found was significant to performance (OR: 0.081, CI: 0.007- 0.909 p=0.042). Community recognition (OR: 1.473, CI: 0.208-10.448 p=0.699), family support (OR: 3.889, CI: 0.176-85.870 p=0.390), and community support (OR: 1.377, CI: 0.153-12.414 p=0.776) does not influence performance. Conclusion: Performances of CHWs in Upper Manya Krobo district, Ghana in the delivery of health care services at CHPS zones were below average or poor. According to the study, with the exception of CHWs’ main source of income, the demographic characteristics did not show statistically significant association with good performance. Health sector participation in the institutionalization and operation of the CHW programme was poor. Consequently, health sector factors were found to be negatively associated with good performance by CHWs. Moreover, community factors which are central in the performance of CHWs according to literature were found to be negatively associated with good performance in the study. Implementation and realization of the key targets in rural setting is challenging therefore, stakeholders need to follow the CHWs guidelines developed. The findings from this research will be useful to researchers, programme implementers, policy makers, and communities in targeting interventions aimed at improving community development programmes, and finally improving the health status of communities.