Integrated community case management and community-based health planning and services in Ghana : assessment of the national implementation for the prevention and management of malaria, diarrhoea and suspected pneumonia

Abstract

Background: Ghana has developed two main community-based strategies that aim to increase access to quality treatment for malaria, diarrhoea and suspected pneumonia, and to improve household and family practices: Home-based Care (HBC) and Community-based Health Planning and Services (CHPS). After two and eight years of HBC implementation in the Volta and the Northern Regions respectively, and more than 10 years of CHPS implementation in both regions, there was the need to assess the performance of these strategies in delivering care and preventive messages for children under-five with fever, diarrhoea or cough. Objectives: To assess (i) the curative component in terms of utilization, appropriate treatment given and client satisfaction; (ii) the preventive component in terms of carers’ disease knowledge and health behaviour and (iii) to determine the cost per case appropriately diagnosed and treated under the HBC and CHPS. Methods: A household survey was conducted in the Volta and Northern Regions. The study population were carers of children under- five who had a fever, diarrhoea and/or cough in the last 2 weeks previous to the survey. In addition, a cost analysis was conducted. Results: HBC utilization was 17.3% and 1.0% in the Volta and Northern Regions respectively, while CHPS utilization was 11.8% and 31.3%, respectively. HBC in the Volta Region was successful in reaching the poorest, contributing to health equity. Less than 50% of malaria, diarrhoea and suspected pneumonia cases received appropriate treatment in both regions and under both strategies. Health education messages from community-based agents (CBAs) in the Northern Region were associated with the identification of at least two signs of severe malaria (adjusted Odds Ratio (OR) 1.8, 95%CI 1.0, 3.3, p=0.04), two practices that can cause diarrhoea (adjusted OR 4.7, 95%CI 1.4, 15.5, p=0.02) and two signs of severe pneumonia (adjusted OR 7.7, 95%CI2.2, 26.5, p=0.01)-the later also associated with prompt treatment (p<0.5). In addition, HBC was associated with prompt care seeking behaviour in the Volta Region and CHPS with prompt care seeking behaviour in the Northern Region. The cost per case appropriately diagnosed and treated was lower under the HBC than under CHPS in the Volta Region. HBC unit costs from the societal perspective were higher in the Northern Region than in the Volta Region and than CHPS due to a high number of CBAs and low preventive and curative activities. However, household costs under the HBC strategy were lower than under CHPS in both regions, reducing the burden of health care cost for families. Conclusions: Several actions should be undertaken to improve HBC and CHPS performance ensuring the availability of drugs and CBAs (particularly in the Northern Region). The contribution of HBC to health equity, reduced household costs, disease knowledge and healthy behaviours may justify the inclusion of HBC (preventive and curative services) in the National Health Insurance Scheme benefit package.