UHC Day 2019
Since signing the Alma-Ata Declaration for primary health care (PHC) in 1978, Ghana has remained committed to achieving health for all. The government adopted the Ghana Primary Health Care Strategy, instituted the Community-based Health Planning and Services (CHPS) approach to improve access to promotive and preventive health care at the community level, and established the National Health Insurance Scheme (NHIS) in 2003 to improve financial access to health services. More recently, the Ministry of Health drafted a roadmap to guide major reforms needed to achieve universal health coverage (UHC) by 2030 — focused on strengthening the PHC system from the district to the community level and includes key strategies for reforming service delivery and improving health financing.
In 2018, the Primary Health Care Performance Initiative (PHCPI) launched a new measurement tool — the Vital Signs Profile (VSP) — to help country stakeholders assess their PHC systems and identify opportunities for improvement. Since then, PHCPI has worked with over a dozen countries to produce VSPs. As a PHCPI technical partner, R4D supported the process in Ghana, which was led by the Policy, Planning, Monitoring and Evaluation (PPME) Directorate of the Ghana Health Service. By working collaboratively with the PPME Directorate and engaging local consultants to provide additional support, R4D advanced an inclusive, country-led process for measuring PHC performance and providing evidence for improving PHC.
As R4D and other development partners look to shift the way they provide technical assistance (TA), we wanted to share a few reflections from our experience in Ghana in applying four key principles to better support country-led processes.
1. Identify opportunities to embed new activities into existing policy priorities and processes.
Ghana, like many other countries, has seen its share of different health system assessment tools over the years. We knew that there was a critical ongoing discourse in Ghana around improving access to PHC services, and shared evidence with local change agents about how the VSP might dovetail with and contribute to that discourse. As a TA provider, it is important to have a nuanced and current understanding of the country’s context to shape support in a way that adds value.
2. Country ownership is essential — this requires more than just nominal stakeholder buy-in, but supporting country champions” who are engaged in and lead the process.
The PPME Director, expressed from the start that it was important for Ghana to take ownership over the process to ensure that the VSP became institutionalized within Ghana’s health system. The PPME Directorate convened and led a multi-stakeholder technical working group that drove the process of populating Ghana’s VSP, while R4D and other PHCPI partners provided technical guidance and facilitation support. Stakeholders later commented that the process that the PPME Directorate set up for producing the VSP was as valuable as the results.
3. Pair external technical assistance with local expertise to ensure that support is contextually appropriate.
We worked with the PPME Directorate to identify two experts from local universities who supported the PPME Directorate and technical working group to complete the VSP. These experts helped adapt the tool to Ghana’s context. For example, they helped facilitate the identification of proxy indicators when data was not available for a standard indicator. They also suggested expanding data collection on PHC system capacity at the sub-national level — this was not originally planned, but ultimately provided rich and valuable information.
4. Align expectations at the outset but be flexible and maintain open communication.
Through our experience, we found that the best-laid plans need to leave space for accommodating new ideas and changing priorities. At the start of our engagement in Ghana, we validated the Government’s interest in the work, discussed how we would work together, and agreed on key deliverables and timelines — but there were still “unknowns” that we could not predict at the outset. Maintaining open lines of communication and flexibility among the different partners involved allowed us to remain adaptable to the current situation.
So, what came out of this experience?
In October 2018, Ghana presented its VSP alongside the other 11 “trailblazer” countries at the Global Conference on Primary Health Care in Astana, Kazakhstan. The Minister of Health’s remarks highlighted findings from the VSP process that showed low service coverage, even though 72% of government health expenditure occurred at the PHC level. Since the conference, the PPME Directorate has disseminated and facilitated discussions around the results of the VSP at the national, regional, district and health facility levels, seeking inputs for a national strategic implementation plan for PHC. The discussions have triggered an interest in adapting the VSP to the sub-national level. In November 2019, PPME convened a stakeholder group to make suggestions for PHC measurement at the sub-national level; they will work with key stakeholders to implement these suggestions in the coming years.
From the outset, the PPME Directorate emphasized a country-led process. This has been critical in the use of the VSP at the national level to garner momentum, develop a PHC strategic implementation plan and adapt the VSP to identify PHC gaps at the regional level as the country works toward UHC in 2030.