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The Navrongo Experiment in Ghana James F Phillips,A Ayaga a Bawah,A & Fred N Binka B

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The Navrongo Experiment in Ghana James F Phillips,A Ayaga a Bawah,A & Fred N Binka B Accelerating reproductive and child health programme impact with community-based services: the Navrongo experiment in Ghana James F Phillips,a Ayaga A Bawah,a & Fred N Binka b Objective To determine the demographic and health impact of deploying health service nurses and volunteers to village locations with a view to scaling up results. Methods A four-celled plausibility trial was used for testing the impact of aligning community health services with the traditional social institutions that organize village life. Data from the Navrongo Demographic Surveillance System that tracks fertility and mortality events over time were used to estimate impact on fertility and mortality. Results Assigning nurses to community locations reduced childhood mortality rates by over half in 3 years and accelerated the time taken for attainment of the child survival Millennium Development Goal (MDG) in the study areas to 8 years. Fertility was also reduced by 15%, representing a decline of one birth in the total fertility rate. Programme costs added US$ 1.92 per capita to the US$ 6.80 per capita primary health care budget. Conclusion Assigning nurses to community locations where they provide basic curative and preventive care substantially reduces childhood mortality and accelerates progress towards attainment of the child survival MDG. Approaches using community volunteers, however, have no impact on mortality. The results also demonstrate that increasing access to contraceptive supplies alone fails to address the social costs of fertility regulation. Effective deployment of volunteers and community mobilization strategies offsets the social constraints on the adoption of contraception. The research in Navrongo thus demonstrates that affordable and sustainable means of combining nurse services with volunteer action can accelerate attainment of both the International Conference on Population and Development agenda and the MDGs. Bulletin of the World Health Organization 2006;84:949-955. ميكن اﻻطﻻع عىل امللخص بالعربية يف صفحة Voir page 954 le résumé en français. En la página 954 figura un resumen en español. .955 The 1978 Global Health Conference programmes remains the subject of rates assessed in the early 1990s were goal of achieving “health for all” by the unresolved policy debate.2 This paper well above national levels. Cultural year 2000 was endorsed by all African discusses the lessons learned from an traditions were known to sustain high governments. Yet, as the new millennn experimental study undertaken by the fertility and impede progress with health nium approached, accessible health Navrongo Health Research Centre to interventions.3 The economy in the care remained a distant dream for most resolve debate about feasible means of study area was dominated by subsistence African households.1 With only a decade attaining the MDGs and ICPD goals. agriculture; literacy was low (particularly remaining to meet the United Nations The Navrongo experiment developed among women); and traditions of marn Millennium Development Goal (MDG) strategies for communitynbased repron riage, kinship and familynbuilding emn of reducing childhood mortality by twon ductive and child health services, tested phasized the economic and security value thirds by 2015, no African country is on the impact of the strategies proposed of large families. Healthncare decisionn and guided national reform based on target. Moreover, expanding access to making was strongly influenced by tran lessons learned. comprehensive reproductive health sern ditional beliefs, animist rites and poverty. vices has also been an unfulfilled goal of Parental healthncarenseeking behaviour African governments. After a decade of The Navrongo experiment: was governed more by tradition than regional commitment to the 1994 Cairo background by awareness of modern healthncare opn International Conference on Populan The Navrongo experiment took place in tions. Conducting experimental research tion and Development (ICPD) agenda, KassenanNankana District, an isolated in such an unpromising locality ensured concern is mounting that reproductive rural northern district of Ghana’s most that any success arising from project health programmes in the region are not impoverished region where health, social interventions could not be dismissed working. In West Africa, in particular, and economic problems severely conn as a bynproduct of favourable economic the demographic role of family planning strain development. Baseline mortality trends and social circumstances. a Policy Research Division, Population Council, One Dag Hammarskjold Plaza, New York, NY, 10017, United States, Correspondence to: James F Phillips ([email protected]). b University of Ghana, Accra, Ghana. Ref. No. 06-030064 (Submitted: 16 January 2006 – Final revised version received: 19 May 2006 – Accepted: 22 May 2006) Bulletin of the World Health Organization | December 2006, 84 (12) 949 Research Reproductive and child health in Ghana James F Phillips et al. The factorial design of the experin an appealing concept if operational family planning services. Chiefs, elders ment was configured with two experin problems with deployment in the comn and women’s groups were involved in mental arms. One arm of the experin munity could be resolved to improve discussing practical means of developing mental design emphasized the value of the accessibility of nurse services. Nurses leadership of operations to deliver comn aligning community health services with already working in the programme had munity health care services.12 Particular the traditional social institutions that been trained to provide curative services attention was directed to mechanisms organize village life. Policy focused on for acute respiratory infections, malaria for fostering community contribution of this perspective received impetus from and other ailments. They could also labour and materials for constructing the an international health conference held provide care for diarrhoeal diseases, imn health compounds to which nurses were in 1987 by the United Nations Children’s munization services and comprehensive to be assigned. The mechanics of launchn Fund (UNICEF)/WHO in Bamako, family planning and safe motherhood ing this programme and listening to its Mali, for African ministers of health.4 care and could be entrusted with care stakeholders generated practical insights The “Bamako Initiative” proposed a and referral services that volunteers into ways of changing programmes from framework for promoting communityn could not provide. Antibiotic therapy, clinicnfocused services to communityn engaged management, financing and basic midwifery services and injectable based care. These steps were clarified by leadership of health services.5 Despite contraceptives were examples of services modifying the programme over time and the conceptual appeal of Bamako, that were available only from nurses. A reconvening focusngroup discussions international appraisals of actual implen brief regimen of additional training was with members of the pilot communities mentation of the proposals generated provided to enable these nurses to organn to gauge their reactions and garner their mixed results.6 Nonetheless, elements nize community health services, engage advice.13 of the Bamako Initiative were adopted in community diplomacy and supervise After a pilot trial of 18 months, as national policy in Ghana, such as a the activities of volunteers. an experimental phase was launched in commitment to developing community In summary, health policy debate 37 communities to test the hypotheses health committees, volunteer services focused on the relative merits of two that strategies developed in the pilot and community financing of essential alternative approaches to extending scheme could lead to reduced fertility 7 drugs. Evaluations of the Ghana pron health care to community locations. and reduced childhood mortality. The gramme showed, however, that turnover The proponents of volunteer strategies factorial design was configured with two 14 of volunteers was high, quality of care was based their arguments on evidence that experimental arms. 8 low and supervision was lax. Reliance on vibrant social institutions could support The “community health officer” arm volunteers remained an appealing policy affordable communitynled services. The of the experiment reoriented existing option, however, because approaches provision of professional nurse services clinical nurses to enable them to provide based on the assignment of professional was supported by evidence that voln community health care and assigned workers led to potential difficulties with unteer programmes were not working these rentrained workers to village locan the sustainability of investment in facilin and that there were a range of health tions with the new designation “communn 9 ties, equipment and personnel. interventions and technologies that only nity health officers.” Nurses entering the The second arm of the experiment nurses could provide. programme had completed 18 months concerned strategies for relocating health of training in basic curative health sern service staff from clinics to community vices, public health, immunization and locations. In the early 1990s, more than Methods family planning. Reorientation involved 2000 “community health nurses” were The experimental design 6 weeks of intensive innservice training hired, trained for 18 months, and den In response to policy debate, a threen in methods of community engagen ployed
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