13.1 Community-Based Health Planning and Services (CHPS) Model

13.1 Community-Based Health Planning and Services (CHPS) Model

Quick Answer: The Community-Based Health Planning and Services (CHPS) initiative represents Ghana's flagship national Primary Health Care (PHC) strategy designed to bridge geographical inequities by relocating frontline health services from static institutional clinics directly to community doorsteps. Derived from the Navrongo Health Research Centre's Community Health and Family Planning experiment in the 1990s, CHPS organises communities into defined zones (commonly about 5,000 people) served by a resident Community Health Officer (CHO) and supported by a Community Health Management Committee (CHMC) and Community Health Volunteers (CHVs). Implementation follows six milestones: preliminary planning, community entry, the community health compound, posting of the CHO, essential equipment and deployment of volunteers. Frontline clinical services focus on Integrated Community Case Management (iCCM) for malaria, diarrhea, and pneumonia, Child Welfare Clinics (CWC), focused antenatal care, and bidirectional referral.

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Primary Health Care (PHC) Framework in Ghana

The delivery of healthcare in Ghana is grounded in the principles of the landmark 1978 Alma-Ata Declaration, which defined Primary Health Care (PHC) as essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford.

Core Principles of Primary Health Care

1. Universal Accessibility and Equity: Health services must be physically and financially accessible to all individuals regardless of geographical location, ethnic background, gender, or socioeconomic status.
2. Community Participation and Self-Reliance: Communities are not passive recipients of health interventions; they are active partners in identifying health priorities, mobilizing local resources, and co-managing health services.
3. Intersectoral Collaboration: Health outcomes depend heavily on non-health sectors, including agriculture (food security), education (literacy and health education), water resources, environmental sanitation, and local road transport.
4. Appropriate Technology: Diagnostic tools, pharmaceuticals, and infrastructure must be scientifically robust, affordable, culturally acceptable, and readily maintainable within resource-constrained environments.
5. Focus on Prevention and Promotion: Emphasis is shifted from expensive tertiary hospital cures toward preventive interventions (vaccinations, vector control) and health education.

Ghana's Three-Tier PHC Operational Architecture

To translate these principles into operational service delivery, the Ministry of Health (MOH) and Ghana Health Service (GHS) organized district healthcare into a standardized three-tier pyramidal structure:

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Historical Evolution: The Navrongo Experiment

During the 1980s and early 1990s, many rural households in Ghana lived far from the nearest static health facility, and infant and under-five mortality were high. To address this crisis, the Navrongo Health Research Centre (NHRC) launched the Community Health and Family Planning (CHFP) Project in the Kassena-Nankana District of the Upper East Region in the 1990s.

The Experimental Design

The Navrongo experiment compared four groups of communities:

• Community mobilisation only: traditional leaders and volunteers (zurugelu approaches) without a resident nurse;
• Nurse only: a community health nurse relocated to live in the community (the forerunner of today's CHO);
• Combined: resident nurse plus community mobilisation;
• Comparison: existing static services.

Findings and National Adoption

Placing resident nurses in communities improved childhood survival, and combining nurses with community mobilisation also helped reduce fertility. The lesson that shaped CHPS was that clinical services work best when traditional leaders, volunteers and community institutions own them.

In 1999, the Ministry of Health adopted the strategy nationally as the Community-Based Health Planning and Services (CHPS) initiative. National rollout commenced in 2000, establishing CHPS as Ghana's primary instrument for achieving Universal Health Coverage (UHC) and addressing the United Nations Millennium Development Goals (and subsequently Sustainable Development Goal 3).

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Core Structural Components of the CHPS Zone

A functional CHPS operational zone consists of four integrated pillars: geography, healthcare personnel, community leadership, and physical infrastructure.

1. Delineation of CHPS Zones

A CHPS zone is a geographically defined operational catchment area encompassing a population of approximately 3,000 to 5,000 individuals (or 500 to 750 households) within a contiguous rural or peri-urban territory. Boundaries are demarcated using natural landmarks, electoral areas, and traditional village boundaries to ensure that every resident can reach the compound within a 30- to 45-minute walk.

2. The Community Health Officer (CHO)

The CHO is the cornerstone of the CHPS model. The Ministry of Health's CHPS policy defines the CHO as a trained and oriented Community Health Nurse working in a CHPS zone. Crucially, the CHO does not commute from an urban centre; the CHO resides inside the community at the CHPS compound and spends much of the working week on doorstep home visits and outreach rather than static clinic work.

3. Community Health Management Committee (CHMC)

The CHMC is the community governing board responsible for local health oversight. Composed of respected community members (including traditional elders, women's group leaders, youth representatives, religious leaders, and the local District Assembly member), the committee:

• Mobilizes local labor and materials for the construction and maintenance of the CHPS compound;
• Ensures security, potable water, and electricity/solar power for the resident CHO;
• Manages emergency community transport schemes (ETS);
• Resolves social disputes and maintains mutual accountability between health workers and community members.

4. Community Health Volunteers (CHVs)

CHVs are non-salaried, literate or semi-literate individuals selected by the community and trained by the Ghana Health Service. Each CHV covers a group of nearby households and assists the CHO by:

• Conducting community mobilization for Child Welfare Clinics (CWC) and national immunization days;
• Tracking immunization defaulters, non-attending pregnant women, and tuberculosis patients;
• Maintaining community registers of vital events (reporting births, maternal deaths, and strange disease outbreaks);
• Distributing long-lasting insecticidal nets (LLINs) and water purification tablets.

5. The CHPS Compound

The physical infrastructure of a CHPS compound is deliberately modest, functional, and culturally integrated. It comprises:

• Clinical consultation and treatment room equipped with diagnostic sets, examination couch, and basic medications;
• Maternity and labor room (where a certified Community Midwife is stationed);
• Cold-chain storage corner (solar or electric refrigerator, vaccine carriers, ice packs);
• Residential living quarters for the CHO, ensuring 24-hour presence for obstetric emergencies and acute childhood illness.

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The Six Implementation Milestones of CHPS

The Ghana Health Service describes CHPS implementation as six milestones, broken down further into 15 operational steps. Skipping community engagement leads to poor ownership and under-use of services.

[ MILESTONE 1 ] Preliminary planning (DHMT mapping, zoning, community profile)
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[ MILESTONE 2 ] Community entry (chiefs and leaders, durbars, Community Health Committee selected and trained)
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[ MILESTONE 3 ] Community Health Compound (community-supported construction or provision)
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[ MILESTONE 4 ] Posting of the CHO (selection, training, introduction to the community, deployment)
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[ MILESTONE 5 ] Essential equipment (clinical equipment, cold chain, motorbike or bicycle, supplies)
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[ MILESTONE 6 ] Volunteers (Community Health Volunteers selected, trained and deployed)

A Ministry of Health review stressed that a CHO should never simply be "posted into a building": community entry, introduction to chiefs and the committee, and a launch durbar come first.

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Customary Protocols for Community Entry in Ghana

In Ghanaian public health practice, clinical proficiency cannot compensate for cultural disrespect. Traditional administrative structures—anchored by the Chieftaincy institution—possess supreme moral authority and social control in rural communities. The nurse must execute meticulous community entry protocols prior to delivering health services.

Traditional Chieftaincy Hierarchy

Public health teams must navigate a defined customary governance hierarchy:

• Paramount Chief (Omanhene in Akan / Naa in Dagbani, Gurune / Togbe in Ewe): Supreme custodian of stool or skin lands;
• Divisional and Sub-Chiefs: Administrative leaders of individual towns and constituent villages;
• Clan Heads and Family Elders: Lineage custodians who influence domestic healthcare decisions;
• Queen Mothers (Ohemaa / Pognaa): Highly influential traditional female leaders who hold paramount authority regarding maternal welfare, childbearing customs, female adolescent rites, and family planning approval;
• Tindanas / Tendambas: Earth priests in Northern Ghana who serve as spiritual custodians of the land and must be consulted regarding compound building sites;
• District Assembly Members and Unit Committee Chairpersons: Elected local government representatives who bridge political and traditional structures.

The Customary Protocol of "Knocking" (Aponkyibɔ)

When entering a new community, the health team does not convene public gatherings immediately. Protocol dictates that the team first seeks audience at the Chief's palace (Ahemfie):

• The Linguistic Intermediary (Okyeame / Linguist): Direct verbal communication with the Chief is culturally improper; visitors address the Chief's linguist, who relays the words to the Chief using formal proverbs.
• Presentation of Customary Drinks: In Akan, Ga, and Ewe regions, the visitors present a customary bottle of schnapps or gin (accompanied by an agreed customary cash token) known as Aponkyibɔ ("knocking fee"). In Northern savannah cultures, visitors present white kola nuts (Bese fitaa) and tobacco, signifying purity of intention, peace, and respect.
• Stating the Purpose: The health team clearly states the health development objective, listens to the counsel of the elders, and requests permission to interact with the wider population.

The Community Durbar

Once the Chief and council grant approval, the Chief instructs the town crier (Dawurubɔfoɔ / gong-gong beater) to convene a Community Durbar. Held beneath central shaded trees or village squares, the durbar is an open, participatory assembly where:

• The Chief or Queen Mother openly endorses the health project, dissolving suspicion and cultural anxiety;
• Health workers present proposed health interventions in the local vernacular;
• Community members voice apprehensions regarding modern pharmaceuticals, vaccinations, or family planning;
• Collective resolutions are formalized through communal applause and customary libation.

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Scope of Services Provided by the Community Health Officer

The CHO functions as a generalized public health clinician, health educator, and epidemiological sentinel. The scope of service encompasses three main domains: preventive care, basic curative management, and doorstep home visits.

                      [ SCOPE OF CHO SERVICES ]
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        +-------------------------+-------------------------+
        |                         |                         |
        v                         v                         v
  [ PREVENTIVE ]            [ CURATIVE (iCCM) ]       [ HOME VISITING ]
  - EPI Immunizations       - Malaria (RDT + ACT)     - Postnatal visits (24h, 7d)
  - CWC Growth Monitoring   - Diarrhea (ORS + Zinc)   - Defaulter tracing (EPI/ANC)
  - Focused ANC Care        - ARI (Amoxicillin)       - Compound sanitation audit
  - Family Planning         - Minor Wound Dressings   - Vital statistics tracking

1. Preventive and Promotive Health Services

• Expanded Programme on Immunization (EPI): Administering routine infant antigens (BCG, OPV, Pentavalent [DTP-HepB-Hib], PCV-13, Rotavirus, Measles-Rubella, Yellow Fever, Vitamin A) through fixed sessions at the compound and mobile outreach sessions in remote hamlets.
• Child Welfare Clinics (CWC): Conducting monthly growth monitoring clinics using Salter scales and mid-upper arm circumference (MUAC) tapes, plotting growth curves on the Road-to-Health chart, and detecting early protein-energy malnutrition (stunting, wasting, kwashiorkor).
• Focused Antenatal Care (ANC): Performing early booking, maternal blood pressure screening, abdominal palpation, urine protein testing, providing Intermittent Preventive Treatment of malaria in pregnancy with Sulfadoxine-Pyrimethamine (IPTp-SP), distributing iron-folic acid supplements, and administering Tetanus-diphtheria (Td) toxoid.
• Family Planning Services: Delivering reproductive health counseling, dispensing barrier methods (male and female condoms), prescribing oral contraceptive pills, and administering injectable progestins (Depo-Provera [DMPA-IM] and Sayana Press [DMPA-SC]). Implants may be provided by CHOs trained to do so; clients wanting an IUD or a permanent method are counselled and referred.

2. Basic Curative Services & Integrated Community Case Management (iCCM)

Under GHS standard clinical treatment guidelines, the CHO manages uncomplicated childhood illnesses using Integrated Community Case Management (iCCM) algorithms:

• Uncomplicated Malaria: Performing malaria Rapid Diagnostic Tests (mRDT) for every febrile child. If positive, dispensing weight-based Artemisinin-based Combination Therapies (ACTs):
  • Artemether-Lumefantrine (AL) (taken with fatty food or milk);
  • Artesunate-Amodiaquine (AA);
  • Dihydroartemisinin-Piperaquine (DHAP).
• Acute Diarrheal Diseases: Assessing hydration status and treating uncomplicated diarrhea with low-osmolarity Oral Rehydration Salts (ORS) to replenish fluids and electrolytes, combined with dispersible Zinc sulfate tablets for 10 to 14 days (10 mg daily for infants < 6 months; 20 mg daily for children >= 6 months) to regenerate damaged intestinal mucosa and prevent recurrent episodes.
• Acute Respiratory Infections (ARI): Utilizing acute respiratory infection (ARI) timers to count breaths per minute. Children exhibiting fast breathing without danger signs (>= 50 breaths/min in infants 2–11 months; >= 40 breaths/min in children 12–59 months) receive oral dispersible Amoxicillin tablets.
• Minor Wound Dressing & Ailments: Cleansing superficial lacerations with antiseptic solution, sterile gauze dressing, and administering simple antipyretics (oral paracetamol).

3. Doorstep Home Visiting

The defining feature of CHPS is that the nurse goes to the client. The CHO spends multiple days each week walking through the zone, visiting 10 to 15 compound households per day:

• Postnatal Home Visits: Clinical assessment of mothers and newborns within 24 to 48 hours of birth, followed by scheduled visits on Day 7, Day 14, and 6 weeks. The CHO examines the umbilical cord stump for omphalitis, promotes exclusive breastfeeding, evaluates lochia, and checks maternal vitals.
• Defaulter Tracing: Cross-referencing immunization and antenatal registers to track dropouts and deliver doorstep vaccinations.
• Environmental Audits: Inspecting compound latrines, refuse pits, animal pens, and water storage containers to eliminate mosquito breeding sites.

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Bidirectional Referral Pathways and Pre-Referral Stabilization

A primary mandate of the CHO is recognizing clinical limitations and initiating prompt emergency transfer. A delay at Level A can result in fatal maternal or pediatric decompensation.

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|                         BIDIRECTIONAL REFERRAL FLOW                               |
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|  [ LEVEL A: CHPS ZONE ]                                                           |
|  - Identifies Danger Signs (Convulsions, obstructed labor, severe dehydration)    |
|  - Administers Pre-Referral Stabilization (Rectal Artesunate, IV Saline, Amox)    |
|  - Completes GHS Standard Referral Form & Activates Community Transport (ETS)     |
+-----------------------------------------------------------------------------------+
                                         |
                         [ URGENT UPWARD REFERRAL ]
                                         v
+-----------------------------------------------------------------------------------+
|  [ LEVEL B: SUB-DISTRICT HEALTH CENTRE ] or [ LEVEL C: DISTRICT HOSPITAL ]         |
|  - Confirms definitive diagnosis & institutes advanced critical interventions     |
|  - Manages parenteral artesunate, blood transfusions, emergency C-section         |
|  - Stabilizes and completes clinical management                                   |
+-----------------------------------------------------------------------------------+
                                         |
                    [ DOWNWARD COUNTER-REFERRAL FEEDBACK ]
                                         v
+-----------------------------------------------------------------------------------+
|  [ LEVEL A: CHPS ZONE ]                                                           |
|  - Receives written counter-referral slip detailing patient discharge outcome     |
|  - Executes domiciliary rehabilitation, medication adherence, and home monitoring|
+-----------------------------------------------------------------------------------+

Critical Danger Signs Requiring Immediate Referral

• Pediatric Danger Signs: Inability to drink or breastfeed, persistent vomiting of all ingesta, convulsions or history of fits, lethargy or unconsciousness, severe stridor or chest indrawing, severe palmar pallor (severe anemia), or severe acute malnutrition with bilateral pitting edema.
• Maternal Obstetric Danger Signs: Antepartum or postpartum hemorrhage, severe headache with visual disturbance and epigastric pain (imminent eclampsia), cord prolapse, abnormal fetal lie during active labor, prolonged labor exceeding 12 hours, foul-smelling vaginal discharge, or maternal fever >= 38.5°C.

Essential Pre-Referral Stabilization Protocols

1. Severe Pediatric Malaria: If a child presents with convulsions, coma, or prostration and cannot take oral medications, the CHO must immediately administer a single weight-based dose of Rectal Artesunate: 100 mg for infants and toddlers aged 6 months to 36 months (under 10 kg), or 200 mg for children aged 3 to 5 years (10–20 kg). The nurse secures the buttocks for 10 minutes to prevent expulsion, then dispatches the patient immediately.
2. Severe Pneumonia: Administer the first dose of oral amoxicillin prior to departure.
3. Severe Dehydration / Shock: Secure intravenous access and initiate IV infusion of 0.9% Normal Saline or Ringer's Lactate running en route.
4. Emergency Transport Schemes (ETS): The CHO contacts the CHMC transport focal point, mobilizing community tricycles ("Motorking" ambulances) or partnering local commercial drivers to transfer the patient without financial delay.
5. Standardized Documentation: Every referral must be accompanied by the official GHS Referral Form, detailing clinical history, physical findings, vital signs, pre-referral medications administered with exact timestamps, and destination facility.

[!IMPORTANT] Exam Alert: CHPS Milestones & Rectal Artesunate Pre-referral Protocol Licensure exam questions frequently test the sequence of CHPS operationalization. Remember the order: planning, community entry (including selecting the Community Health Committee), the compound, CHO posting, equipment, then volunteers. In emergency therapeutics, remember that rectal artesunate is purely a pre-referral single-dose stabilization measure; it never constitutes a curative standalone regimen and must be followed by comprehensive parenteral artesunate at Level B or C.

[!NOTE] Clinical Pearl: Customary Community Entry and the Role of Queen Mothers When introducing maternal and child health interventions (such as family planning, exclusive breastfeeding, or HPV vaccination), always secure the explicit blessing of the Queen Mother (Ohemaa / Pognaa). In many Ghanaian communities, patriarchal chiefs will refer matters concerning women's reproductive health and adolescent rites to the Queen Mother. Her public endorsement eliminates maternal hesitation faster than any clinical lecture.