Rebekah King*, Mohammed Ali**, Sneha Patel***, Peal Kyei****, Samuel Mayeden*****
*CIRCLE Project, **Catholic Relief Services, ***Columbia University, ****Regional Institute for Population Studies, *****Ghana Health Services
In Ghana, many women still do not access healthcare services for themselves or their children. In 2016, more than half of pregnant women in the Volta Region gave birth without a skilled health provider. There are many reasons for this: health facilities are distant or difficult to reach; services are too expensive; there are not enough health providers, and in some cases cultural norms do not support seeking care (e.g. women do not have the autonomy to make decisions). In other cases, women and children facing emergencies cannot reach higher level facilities because of poor transportation options, communication and referrals systems. Women and families who manage to access health facilities do not always receive the desired quality and respectful care that they deserve. The situation is similar in other regions across Ghana.
Catholic Relief Services (CRS) and Columbia University (CU) Mailman School of Public Health (MSPH) sidHARTe Program have a long history of overcoming these challenges and improving emergency care. These programs work to overcome these challenges by cascading capacity building as well as maternal, newborn and child health (MNCH) in Ghana through projects linked to the Ghana Health Service-led Community-Based Health and Planning Services (CHPS) and other programs. CRS and CU responded to the USAID Health Research Program’s call to develop solutions to improve care-seeking behavior, quality of services, and referrals systems using implementation research through a Broad Agency Announcement (BAA) on care-seeking and effective referrals. CRS and CU submitted proposals independently and were invited to attend a co-creation workshop in May 2018 in Johannesburg, South Africa.
A Novel Approach to Finding Solutions
Like many donors, USAID uses funding opportunities to identify solutions to development challenges. Unlike traditional USAID procurement, the BAA process is an approach that brings applicants together to collaborate, exchange ideas, test thinking and co-design programs and interventions. This process is aimed at creating solutions that are innovative and better reflect end users’ needs and interests.
CRS and CU proposed to build on previous projects to study the implementation of interventions to address the Three Delays: timely decision(s) to seek care; referral process in reaching health facility; and receiving definitive high-quality care. Each initiative would be integrated with the CHPS+* program. Both groups came to the workshop with the intent of refining their own proposals, yet through the co-creation process, something different happened.
How the BAA Process Led to an Unlikely Collaboration
The BAA process challenges traditional funding and program design approaches. It assumes that developing intervention design concepts in a collaborative manner leads to better ideas and more innovative program solutions. At the co-creation workshop, teams, comprised of a researcher, policy maker and implementer, were encouraged to reflect on end users’ experiences, exchange ideas with other applicants, and use these new insights to improve their proposals.
Through workshop exercises, consultations with experts and cross team exchanges, CRS and CU recognized that their approaches were complementary, and that a collaborative effort would be more competitive. At the suggestion of the government implementation lead, GHS, CRS and CU decided to join forces to develop a stronger, more comprehensive approach. This unexpected partnership became the foundation for the development of the Acute Care and Emergency Referral Systems (ACERS) consortium.
ACERS: Using Implementation Research to Shape Emergency Referrals Systems for MNCH in Ghana Overview
ACERS is a three-year implementation research and capacity building project that aims to promote timely health-seeking behaviors, effective referral systems, and high quality of care to improve maternal and perinatal emergency health outcomes in Ghana. The project is implemented in collaboration with the Ghana Health Service (GHS), Columbia University (CU) Mailman School of Public Health sidHARTe Program, and Regional Institute for Population Studies (RIPS). As an official program of the Government of Ghana, ACERS is fully integrated into GHS’ CHPS+ program as well as GHS health centers and district and referral hospital system. Project activities will address the Three Delays to care and contribute to improved:
- Knowledge, attitudes and behavior of women to seek timely and appropriate emergency obstetric and newborn care (EmONC) services;
- Accessible, affordable and clinically informed emergency dispatch and referral system
- Timely, respectful and evidence-based quality EmONC services
ACERS aims to reduce perinatal and maternal deaths and strengthen the service delivery systems in the Northern and Volta regions. The project includes an implementation research component that will test whether separate components of care can be improved iteratively and combined into a single system that can be scaled-up across the country. The research will also determine the added value of acute care capacity building at the community, sub-district, and district levels of primary health care.
Engaging Country Stakeholders
In September 2018, USAID funded CRS and its partners to implement ACERS. Since the BAA co-creation workshop process was so valuable in developing the final proposal, the consortium decided to conduct a similar process locally. In January 2019, a co-design workshop was held in Accra to engage more stakeholders in refining the ACERS project design. The Accra workshop marked the first time a Health Research Program BAA awardee attempted to replicate co-creation workshop activities at the country level. This process helped to ensure that the ACERS theory of change, results framework and implementation research approach were grounded in best practices and reflected partners’ and key stakeholders’ inputs.
The workshop also brought partners together face-to-face for the first time to foster team building and clarify roles and responsibilities. In addition to consortium partners, the meetings included representatives of national, regional and district level government, the National Ambulance Service, the National Teleconsultation Initiative, teaching hospitals, the National Health Insurance Authority, the University for Development Studies and other USAID funded implementing partners working in care-seeking and MNCH. The Accra co-design workshop was tailored to the ACERS project and enabled the consortium to tap into local knowledge and expertise, that was not represented in Johannesburg, to gather timely, relevant and context-specific ideas for the project design.
“The co-design [workshop] in Ghana brought in field level managers and GHS staff working at district and local levels…. Their inputs and ideas were current…. and brought to the forefront the situation on ground, [including] the health system constraints they encounter daily.” — ACERS Consortium member
ACERS will continue to keep these stakeholders engaged, as they are essential to successful implementation and long-term sustainability of the project. Participants believed the workshop was critical to establishing a strong partnership, enhancing the project design and approach and engendering a sense of ownership among all stakeholders.
The Health Research Program plans to launch a community of practice to connect its care-seeking and effective referrals awardees and others working on these issues to exchange information, best practices and lessons learned. The community of practice will help support stakeholder engagement and leverage their experiences to problem solve, improve implementation and achieve results.
The ACERS project is a prime example of the benefits of using a co-design process to develop solutions to MNCH challenges. Flexibility, collaboration and purposeful stakeholder engagement resulted in a robust approach to improving timely care-seeking, effective referrals and quality of care in Ghana.
The ACERS project is in the final stages of planning and will formally launch in April 2019.
ACERS Intervention Activities
ACERS Interventions by Delay
*CHPS+ is the second phase of the CHPS program
- GHS (2017) Health Performance Review Report for 2016, Volta Region, Ghana.
- Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med 1994; 38: 1091-1110