The Invisible Frontliners: Rethinking Community Health Engagement in Urban Ghana

By Selase Odopey. CHORUS Ghana Project Coordinator & Qualitative Researcher, University of Ghana

To read the Blog post in PDF format click here – Invisible Frontliners

CHORUS Ghana values local stakeholder collaboration in our research. During the needs assessment phase, we partnered closely with Community Health Nurses and Officers (CHNs/CHOs) under the Community-based Health Planning and Services (CHPS) programme. Their support was crucial in conducting community entry activities, transect walks, developing rich pictures, and facilitating individual interviews and focus group discussions. However, during one of these focus group discussions, I encountered a moment of irony—and concern. The very CHNs and CHOs tasked with engaging communities were virtually unknown to the people they were meant to serve.

A Telling Conversation

On this day, after establishing rapport with community leaders, we gathered residents for a focus group discussion. When the topic of CHOs and the CHPS system arose, a young male participant asked, “Where are they? We don’t know them. We don’t see them.”

I pointed out that the woman who had helped organize the discussion was, in fact, a CHO. He looked unconvinced. Following my research training, I maintained a neutral expression, but his words lingered in my mind.

A Disconnect Between Presence and Perception

CHOs report conducting household visits, school health outreach, church and mosque engagements, wellness clinics, and even mass immunizations. Their work spans all age groups and health concerns. So why are they so invisible to the very communities they serve?

In earlier interviews, residents often associated CHOs solely with maternal and child health. Some referred to them as the nurses who vaccinate babies—or more recently, adults during the COVID-19 pandemic. The broader scope of their work remained largely unrecognised.

Critical Questions About CHPS

This experience left me pondering:

• Why are the efforts of CHOs so unseen?
• Why do communities perceive them as having limited capabilities?
• If CHPS is Ghana’s flagship initiative for achieving Universal Health Coverage (UHC), is it truly fulfilling that promise?

CHPS was designed to enhance community ownership of primary healthcare by bringing services closer to people’s homes—particularly in rural areas. This approach was originally tested in a landmark plausibility trial conducted by the Navrongo Health Research Centre in the early 2000s1. Though resource and organisational constraints have hampered its full-scale rollout2, CHPS remains central to Ghana’s UHC vision.

Recent Data and Ongoing Challenges

Recent assessments provide insight into the current state of CHPS:

• As of 2022, all 261 districts in Ghana’s 16 regions have initiated CHPS implementation at various levels, with approximately 76.9% of CHPS zones exhibiting some level of functionality (3)
• Despite these efforts, challenges persist. A systematic review highlighted pervasive issues such as inadequate logistics, insufficient skilled personnel, and poor documentation, which hinder the attainment of UHC by 2030 (4).
• Additionally, while CHPS has been effective in reducing under-five mortality and increasing the use of family planning services5, its impact in urban areas remains limited due to factors like high population density and diverse health-seeking behaviours  (4).

What Next for CHPS in Urban Spaces?

Given these challenges, more questions emerge:

• Are the bottlenecks in CHPS implementation being sufficiently explored?
• What kind of interventions could strengthen its visibility and impact?
• Can CHPS remain relevant in urban and pluralistic health systems?
• Is scaling CHPS in urban settings a worthwhile investment?

As our participatory research transitions into the co-design, implementation, and evaluation phases, these questions guide our thinking. To strengthen CHPS, we must consider innovative, multi-dimensional approaches that make CHNs and CHOs visible, valued, and impactful within the communities they serve.

Sources

Footnotes
1. Nyonator, F. K., Awoonor-Williams, J. K., Phillips, J. F., Jones, T. C., & Miller, R. A. (2005). The Ghana Community-based Health Planning and Services Initiative for scaling up service delivery innovation. Health Policy and Planning, 20(1), 25–34. https://doi.org/10.1093/heapol/czi003
2. Wright, J., Sharma, G., Wurie, H., et al. (2020). Health systems strengthening in Ghana, Sierra Leone and Zambia: examining the role of CHPS and similar community-based models. BMJ Global Health, 5(8), e002955. https://doi.org/10.1136/bmjgh-2020-002955
3. Ghana Health Service. (2022). CHPS Implementation Status Report. Retrieved from https://www.unicef.org/ghana/media/5001/file/%202023%20%20Health%20Budget%20Brief.pdf
4. Elsey, H., Abboah-Offei, M., Vidyasagaran, A. L., et al. (2023). Implementation of the Community-based Health Planning and Services (CHPS) in rural and urban Ghana: a history and systematic review of what works, for whom and why. Frontiers in Public Health, 11, 1105495. https://doi.org/10.3389/fpubh.2023.1105495
5. Ghana Health Service. (2022). CHPS Implementation Status Report. Retrieved from https://www.unicef.org/ghana/media/5001/file/%202023%20%20Health%20Budget%20Brief.pdf