Time to actively involve communities in healthcare quality monitoring and improvement: sharing the WOTRO-COHEiSION experience in Ghana

By the WOTRO-COHEiSION Ghana Project

Authors: Edward Nketiah-Amponsah; Robert Kaba Alhassan; Stephen Opoku Duku

Previous blogs on the KTNET platform by David Roger Walugembe and Denis Muhangi on community engagement attest to the increasing relevance of community engagement to health systems in Africa. The concept of community engagement has been explained differently in the literature depending on the context and scope of application. However, the definition by Morgan and Lifshay (2006) in the context of public health states that community engagement refers to efforts that promote a mutual exchange of information, ideas and resources between community members and health authorities.

Active engagement of communities in health service provision and improvement of public health outcomes is increasingly prescribed as a compelling strategy for resource constrained countries globally. Indeed, an African Union (AU) policy brief (2013) reiterated the importance of community engagement indicating it is essential to ensuring sustainable achievements beyond the lifespan of donor projects in Africa. Community engagement harnesses existing potentials of grassroots resources and promote ownership and acceptability of health policies. The positive impact of systematic community engagement on child and maternal health outcomes (Hounton et al, 2009) and health insurance participation (Setswe et al, 2013) has been demonstrated in some countries in Africa.

In this blog the WOTRO-COHEiSION project seeks to share its experiences in the design and implementation of community engagement interventions aimed at promoting client-centered approach to healthcare quality improvement in clinics/health centres accredited by the national health insurance authority (NHIA) of Ghana. 

Per the interventions design, intervention facilities in selected districts in two regions of Ghana were monitored and assessed by existing community groups/associations on the quality of health services provided to clients. Parameters used for the quality assessment included staff attitude, respectfulness, punctuality, responsiveness to clients’ needs, queuing system and avenues for complaints. The groups/associations engagement sessions were facilitated by trained community volunteers who in turn reported the community responses to the WOTRO-COHEiSION project team through the district director of health services. Feedback and stakeholder workshops (involving clients, health providers and health insurance authorities) were later conducted to communicate concerns of clients for quality improvement.

Details of the community engagement interventions can be found in published articles emanating from the WOTRO-COHEiSION Project (Alhassan et al, 2015; Alhassan et al, 2016). Below is a figure demonstrating implementation steps of the community engagement interventions implemented for nearly one year.

Fig 1: Systematic Community Engagement (SCE) implementation steps

Source: WOTRO-COHEiSION Ghana Project baseline and follow-up field data (2014); Legend: C=Client; P=Provider; I=Insure; NHIS (National Health Insurance Scheme); NHIA (National Health Insurance Authority)

Before and after the community engagement interventions, quality care assessments were done and it was found that adherence to quality care practices had improved in facilities monitored by community groups/associations than those that were not (Alhassan et al, 2015). Improvements were observed in clinics’ leadership and accountability practices; staff competencies; environmental safety; clinical care, and patient safety markers. Besides quality care improvement, quantity of service output increased especially in child and maternal health services, after the community engagement (Alhassan et al, 2015). These outcomes suggest active engagement of communities in quality improvement efforts of health facilities and will not only enhance client’s experiences and perceptions of health service quality but also contribute towards technical quality improvement and higher efficiency levels in health facilities.  

The lesson is that healthcare systems might not attain desired quality care standards in health facilities when communities are relegated to the background and local resources are untapped. Community engagement in healthcare quality improvement is particularly important to resource constrained countries because there is the need to complement central governments’ efforts with more innovative cost effective (yet efficient) strategies like community engagement interventions. The WOTRO-COHEiSION experience demonstrates that community engagement interventions can be sustained if the groups/associations are already existing groups and engagement activities are championed by the community. This creates a sense of ownership needed to promote sustainability.  

References

African Union (AU). Draft Policy Brief for the International Conference on Maternal, Newborn and Child Health (MNCH) in Africa. Johannesburg, South Africa, 1 – 3 August, 2013

Alhassan RK, Nketiah-Amponsah E, Spieker N, Arhinful DK, Ogink A, van Ostenberg P, and Rinke de Wit TF. Effect of community engagement interventions on patient safety and risk reduction efforts in primary health facilities: evidence from Ghana. PLoS One, 2015 10(11): 1-19.

Alhassan RK, Spieker N, Nketiah-Amponsah E, Arhinful DK, Rinke de Wit TF. Perspectives of frontline health workers on Ghana’s National Health Insurance Scheme before and after community engagement interventions. BMC Health Services Research, 2016 16(192): 1-11

Hounton S, Byass P and Brahima B:  Towards reduction of maternal and perinatal mortality in rural Burkina Faso: communities are not empty vessels, Global Health Action, 2009, 2

Morgan MA, Lifshay J: Community Engagement in Public Health, Contra Costa Health Services, Public Health Division. May, 2006.

Setswe G and Witthuhn J: Community engagement in the introduction and implementation of the National Health Insurance in South Africa, Journal of Public Health in Africa 2013,4:e6