1. Does CHPS Increase Access to Family Planning in Rural Ghana? A case study of Nkwanta District Dr. J. Koku Awoonor-Williams Nkwanta Health Development Centre District Director of Health Services, Ghana Health Service

2. Nkwanta Background

3.  Poorest and most remote district in the Volta Region  Spans over 5,500 km 2  Estimated population 187,000  Multiple ethno-linguistic groups  No access to pipe-borne water, telephones, or radio  Several communities only accessible by foot, river or motorbike Nkwanta Background

4.  Nkwanta District doctor: patient ratio 1 : 93,500  Nkwanta nurse: patient ratio 1 : 9,000  High prevalence of water-borne disease and malnutrition  High maternal & infant morbidity and mortality Nkwanta Background

5. Community-based Health Planning and Services (CHPS) Nkwanta first piloted CHPS in 1998 Nkwanta has 9 CHPS zones with 5 more scheduled for launching in 2005 CHPS targets remote, underserved areas CHPS is a vehicle for delivering GHS community level services Approximately 35% of Nkwanta’s total population is covered by CHPS

6. The CHPS Process

7. The operational unit is a CHPS zone Six “milestones” are completed in the process of CHPS implementation

8. CHPS Milestones A CHPS zone is mapped and demarcated Community leaders are oriented and involved in planning activities Community assists in building a “Community Health Compound” (CHC), where the nurse lives and provides 24- hour services

9. CHPS Milestones Community Health Officer (CHO) is trained and relocated to the zone Equipment and transportation are procured Volunteer health organizers are mobilized, trained and deployed

10. Nkwanta District Evaluation Survey (NDES 2004) 60 EA cluster survey with 15 households randomly selected in each cluster Every female aged 15-49 in household was interviewed NDES 2004 includes 859 households and 1,159 female respondents (39% with CHC as nearest facility, 27% in CHPS zones)

11. NDES 2004 Household Characteristics Non- CHPSCHPS CHPS % NDES 2004 Total Number of households65624027%896 Number of female respondents84231727%1,159 Number of children under age five97037828%1,348 Total household population4,6501,74327%6,393 Average household size7.097.26---7.14 Average age of household head44.6244.16---44.50 % households headed by women6%7%---6% % HH in wealthiest 20 %tile asset ranking21%15%---20% Avg. est. annual individual income ($)$692.52 $180.53---$548.01 % indiv. earning < poverty line ($1/day)88%92%---89%

12. CHPS Increases Geographical Access

13. Barriers to Family Planning Economic barriers Administrative/bureaucratic barriers Information/educational barriers Psychosocial/cultural barriers

14. CHPS Increases Economic Access Trust-based payment schemes (deferment, installment, or transfers in-kind) Decreases transportation and opportunity costs (increasing bargaining power of FP clients during spousal negotiations) CHPS services are less expensive than hospital or clinic care (home consultations are free)

15. CHPS Increases Administrative Access & Reduction of ‘Unmet Needs” 24-hour availability of family planning services Routine door-step visits Active outreach strategy for family planning and immunization (CHPS nurses track down clients) Reduction in wait time Flexible and confidential arrangements for service provision (in comfortable and safe environment of clients’ choosing)

16. CHPS Increases Information Access Health education and communication at both community and individual levels Information access includes: health education, symptom recognition, benefits and costs of needed care, and referral services

17. CHPS Increases Cultural Access Community-based nurses understand cultural fears, local superstitions and practices Clients are more comfortable with nurses who live in community CHPS mobilizes local traditions/systems for communication, planning and action

18. CHPS Increases Partner Support 38% of females living in CHPS zones (and ≤15km from CHC) reported that their sexual partner approves of family planning VS. 28% of women with no facility access or non- CHPS facility access

19. CHPS Increases Knowledge of Specific FP Methods

20. CHPS Increases Number of FP Methods Known

21. CHPS Increases FP Use vs. Females Without Facility Access

22. CHPS Increases FP Use Among Women With Only Primary Education CHPS zones- 36% VS. Hospital access- 20% Health centre or clinic access -7-8% No facility access -13%

23. Living Near CHC Is Not Enough

24. CHPS Decreases Fertility

25. Barriers to Family Planning Use

26. Lessons Learned: Areas for Improvement

27. Keeping communities mobilized Creating volunteer incentives Reaching vulnerable ethnic groups Involving formal female social networks (market associations, etc…) Promoting male partner participation Launching adolescent programs Lessons Learned: Areas for Improvement

28. Conclusions and Policy Implications

29. Conclusions and Recommendations CHPS increases geographical and non- geographical access to family planning CHPS increases knowledge, use and support for family planning National policies should allow midwives and CHOs to provide all FP methods (including IUD and Norplant)

30. Thank You Very Much You are invited to Nkwanta!