Elsevier

Evaluation and Program Planning

Volume 72, February 2019, Pages 170-178
Evaluation and Program Planning

Willing but unable? Extending theory to investigate community capacity to participate in Ghana’s community-based health planning and service implementation

https://doi.org/10.1016/j.evalprogplan.2018.10.001Get rights and content

Highlights

  • Limited community capacity to participate in CHPS.

  • Individualism, apathy and weak communal ties weakened social support for CHPS.

  • Men and women informal groups demonstrated high capacity to support CHPS.

  • Individuals acted in low voluntary capacity for CHPS implementation.

  • Poverty affected the communities’ capacity to provide financial support for CHPS.

Abstract

While primary health care programmes based on community participation are widely implemented in low- and middle- income settings, empirical evidence on whether and to what extent local people have the capacity to participate, support and drive such programmes scale up is scant in these countries. This paper assessed the level of community capacity to participate in one such programme – the Community-Based Health Planning and Service (CHPS) in Ghana. The capacity assessments were drawn from Chaskin’s (2001) theorised indicators of community capacity with modifications to include: sense of community; community members commitment; community leadership commitment; problem solving mechanisms; and access to resources. These capacity measures guided the design of an interview guide used to collect data from community informants, frontline health providers (FLP) and district health managers. Key qualitative themes were built into a questionnaire administered to households selected through systematic sampling approach. Findings showed that growing individualism, low trust in neighbours and apathetic behaviours undermined the capacity of mutual support for CHPS. The capacity to support CHPS was high for local leadership and community social mobilisation groups who often dedicated time to working with FLP to promote maternal and reproductive health service use, and in advocating broader support for CHPS. Within the wider community, commitment to voluntarism was low as members perceived CHPS to be owned by, and run on government funds and resources. Poor voluntarism was compounded by poverty that crippled the capacity to provide needed resource support for CHPS. Findings have great implications for building strong capable communities for participation in community oriented health programmes.

Introduction

In Low and Middle Income Countrieswhere centrally controlled health programmes often fail to make significant impact, community participation is seen as the way to make health systems results oriented (Rifkin, 2014; Rosato, Laverack, & Grabman, 2008). Community participation although an age-old concept associated with the 1978 Alma Ata proclamation of primary health care, has remained relevant in contemporary global health policy discourse (Draper, Hewitt, & Rifkin, 2010; Rosato et al., 2008). Within the last decade, for example, community participation has been revitalised by a number of international health policy initiatives – the Millennium Development Goals, the Every Newborn Action Plan, the Integrated Management of Childhood Illnesses among others that strongly encourage strong community involvement in promoting health and well-being (Juma, Owuor, & Bennett, 2015; Rosato et al., 2008). Such global initiatives were necessitated by evidence showing primary health care founded on community participation results in quality and cost-effective health service delivery (Morgan, 2001), and that targeted programmes and strategies designed to improve maternal, child and newborn survival and tackle disease burden of the poor triumphed with community involvement (Lewin, Lavis, & Oxman, 2008; Rifkin, 2014; Rosato et al., 2008).

Community participation has traditionally been viewed from the lens of utilitarian (participation as a means to and end) and empowerment (participation as an end in itself) in pursuing social change (Morgan, 2001; Pérez, Lefèvre, & Romero, 2009). Central to both traditions of participation is that the community acts as an agent in defining, diagnosing and prioritising solutions to problems confronting health (McLeroy, Norton, Kegler, Burdine, & Sumaya, 2003). While scholars remain polarised on the specific mechanisms that can be deployed to maximise participation from the utilitarian and empowerment lens (Pérez et al., 2009), there is somewhat consensus that participation as a means to attaining prescribed programme goals is influenced by the capacity to participate in driving such efforts, and in providing inputs to sustain gains into the long term (Rifkin, 2014).

Community capacity has been given diverse interpretations, creating confusion about its precise meaning. Nonetheless, despite the many definitions proffered (see for example: Goodman, Speers, & McLeroy, 1998; Laverack, 2005; Wendel, Burdine, & McLeroy, 2009), they seem unified in Chaskin’s (2001: 4) definition of community capacity as ‘…a community’s human, organisational and social capital that can be leveraged to solve collective problems, and improve or maintain well-being; it may operate through informal social processes and/or organised efforts by individuals, groups, networks of associations and the broader system of which the community is part’. From this point of view, capacity is seen as the bedrock of a functional community participation as it determines the ability to mobilise, network and collectively solve health problems.

The capacity to participate in health is reported to have profound benefits. Notably, it motivates actions in addressing problems of programmes implementation (Hickey & Mohan, 2004; Mansuri & Rao, 2004), offsets cost of health delivery, increases broad-based support and health service use, thereby improving confidence in the health system (Alfonso, Nickelson, & Hogeboom, 2008; Millar, Robertson, & Allender, 2013). Alfonso et al. (2008) and Goodman et al. (1998) highlighted the importance of capacity; noting it is linked to programme ownership, where community members act as champions to communicate goals, motivate each other, obtain resources and spearhead implementation. Systematic efforts by international bodies including the World Bank, UNICEF and World Health Organisation to devolve some elements of management and delivery of health services to the community (Bhutta, Ahmed, & Black, 2008), means that capacity cannot be ignored in health programmes scale up, and doing so will be problematic as real life implementation decisions and actions are tied to the individual and collective will to participate in providing needed support systems.

While knowledge on the importance of community capacity proliferates, empirical evidence on whether and to what extent local people have the capacity to participate and support community-based health programmes implementation is poorly documented. This has created room for multiplicity of assumptions regarding what a capable community is (Gibbon, Labonte, & Laverack, 2002; Goodman et al., 1998; Wendel et al., 2009), further comprising empirical endeavours of this important field. Researchers have theorised indicators of community capacity ostensibly to minimise speculations surrounding the concept – but studies testing these indicators in health programmes context are not only few (Draper et al., 2010; Gibbon et al., 2002; Laverack, 2005), but that they have been conducted outside the context of sub-Saharan African (SSA), which is home to a significant number of community-based interventions (Rosato et al., 2008). Also, such studies clearly lack sufficient empirical and subjective measures of capacity from the community’s own perspective. The knowledge vacuum is often a barrier to SSA governments and health stakeholders’ efforts at making informed decisions on building capable communities for participation in health programmes.

This study sought to contribute to the knowledge gap by drawing on theory to empirically assess the level of community capacity to participate in Ghana’s community-based health planning and service (CHPS) programme implementation. CHPS is a national primary care programme modelled on the Alma Ata primary health care tenets – community participation, inter-sector partnership and use of cost effective local resources (Lawn, Rohde, & Rifkin, 2008). CHPS emerged from a successful community trial in northern Ghana in the late 1990s targeting reduction in maternal and childhood mortalities. It was subsequently integrated into the health system as a primary health care policy with nationwide scale up in 2002 (Nyonator, Awoonor-William, Phillip, Jones, & Miller, 2005). CHPS implementation requires active involvement of the district health managers, community members and community-based health providers. Within the community, CHPS relies on voluntarism, supportive leadership, social mobilisation and local resource support to deliver health services at scale (Fig. 1) (Nyonator et al., 2005). Detailed information about CHPS can be found elsewhere (Awoonor-Williams, Sory, & Nyonator, 2013; Nyonator et al., 2005; Phillips, Bawah, & Binka, 2006). To our knowledge this study is the first to assess community capacity to participate in CHPS, and it comes at a crucial time where government and international partners are seeking evidence to strengthen community involvement in its implementation. Thus, findings will drive policy efforts on maximising community capacity to participate in the programme.

Section snippets

Theoretical framework

This study drew upon Chaskin (2001) theory of community capacity to assess the level of community capacity to participate in CHPS. Chaskin theorised four indicators of community capacity: sense of community; commitment among community members; mechanisms of problem solving; and access to resources. Sense of community describes the nature and quality of social ties for mutual benefits. It is determined by mutual concern for community issues, shared values as well as norms that propel common

Demographic characteristics of participants

Demographic characteristics of participants are shown in Table 2. Participants in the qualitative study were older (X¯ = 37) than those in the quantitative study (X¯ = 32). The majority of participants in both studies had no formal education and farming was the main occupation.

Community capacity to participate in CHPS

This section presents findings of both the qualitative and quantitative data on the capacity to participate in CHPS applying Chaskin (2001) community capacity indicators: sense of community (shared values and social

Discussion

CHPS is more than just a medium of health service delivery. It encompasses community participation, mobilisation and social support systems in reducing cost of care delivery and promoting social accountability mechanisms in health governance at the micro level (Nyonator et al., 2005). As participation is paramount to sustainable CHPS implementation in achieving target objectives, this study sought to determine whether and how local people have the capacity to participate in it, with the

Conclusion

Policy makers seeking strategies to strengthen CHPS implementation can benefit from the study’s findings in a number of ways. First, since social capital is important for building and sustaining community values towards mutual beneficial relationship (Woolcock, 2001), we suggest the initiation of strong community networking programmes that will allow for formal and informal meetings and promotion of horizontal collective action. Brune and Bossert (2009) noted how such networks helped build

Conflict of interest

None.

Funding

This study received support from the African Doctoral Dissertation Research Fellowship by the African Population and Health Research Centre, Nairobi Kenya (Grant number: 2014-2016 ADF 001) for the first author’s doctoral thesis work. The Centre played no role in the development and writing of this manuscript.

Acknowledgements

We are deeply grateful to all the field assistants for their immense efforts during the data collection process. We would also like to thank the District Health Directors and all the participants for making time to participate and provide invaluable information for the study.

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