COMMUNITY HEALTH

NURSES’TRAINING COLLEGE –
TAMALE

COMMUNITY NURSING 11 (NAP 031)

COMMUNITY –BASED HEALTH
PLANNING AND SERVICES (CHPS)
 Lesson objectives
By the end of the lesson, students would be able to:

1. explain meaning of CHPS

2. explain the evolution of CHPS

3. explain CHPS concept / policy

4. outline CHPS policy Objectives and explain them appropriately

 What is CHPS
CHPS’ represents Community-Based Health Planning and
Services
It is a national health policy / strategy/ initiative
for implementing primary health care (PHC) that aims to reduce
barriers to geographical access to health care by reorienting and
relocating health services delivery from the sub-district health
centers ( level B) to locations in the communities (level A).
It is a process of health care provision in which health workers
and community members are actively engaged as partners in
delivery of PHC.
CHPS is a national Strategy to deliver
essential community based health services
involving planning and service delivery with the
communities.
• Its primary focus is communities in deprived sub-
districts and in general bringing health services
close to the community
Why the emphasis on rural community?
• Because in Ghana,
1. Geographical access is a major barrier to health care
and maternal and infant morbidity and mortality is
related to service inaccessibility.
2. The Bio-Medical Cure Model is preoccupied with illness and disease

GAP
3. Trained health workers refused posting to rural
areas
4. Poor transport system( poor road network, few
vehicle)
 The Community-based Health Planning and
Services (CHPS) Concept
• CHPS began as a Community Health and Family Planning
(CHFP) project based on lessons learnt from Bangladesh
(Phillips, 1988).
• The project was launched in Navrongo as an operations
research in 1994 and piloted in three sub-districts.
• Four different models of delivering community services were
experimented to treat malaria, acute respiratory infections,
diarrheal disease and other childhood illness as well as
provide family planning services and immunisation outreach.
• Following the successful implementation of the Navrongo
project, Ghana adopted the Community-based Health Planning
and Services (CHPS) program and implemented same for over
10 years.
• Considered one of the pragmatic strategies for achieving
Universal Health Coverage of a basic package of essential
primary health services, CHPS has gained international
recognition.
• Led by a Community Health Officer (CHO) and supported by
volunteers drawn from the area of service, the CHPS strategy is
a breakthrough in enhancing community involvement and
ownership of primary health care interventions towards
achieving universal health coverage (UHC).
CHPS became a breakthrough in enhancing
community involvement and ownership of PHC
interventions towards achieving Universal Health
Coverage.
• In 1996, results of the pilot suggested that relocating a
nurse to communities could outperform an entire sub-
district health centre, increasing the volume of health
service encounters in pilot communities and
simultaneously improving immunization coverage and
Family Planning coverage.
In 1999, consensus was reached to adopt and scale
up the CHPS initiative as a national strategy to
improve access, efficiency, and quality of health care
based on the Nkwanta experience.(Ghana Health
Service, 2003).

As of June 30, 2002, 95 out of 110 districts have

launched the planning stage of the CHPS
programme
Ministry signed a performance contract in 2011 and
2012 with the Ghana Health Service to accelerate the
rapid deployment of CHOs into demarcated CHPS
Zones. The new zones are to be coterminous with the
District Assembly electoral areas.
 The Aim & General Principles of the CHPS policy

The Aim:
To attain the goal of reaching every community with a
basic package of essential health services towards
attaining Universal Health Coverage and bridging the
access inequity gap by 2020
 General Principle
The general principles guiding the development and implementation
of CHPS are
Community participation, empowerment, ownership, gender
considerations and volunteerism
Focus on community health needs to determine the package of
CHPS services
Task shifting to achieve universal access
Communities as social and human capital for health system
development and delivery
Health services delivered using systems approach.
CHO as a leader and community mobilizer
 Policy Objectives

 Improve equity in access to basic health

services
 Improve efficiency and responsiveness to client
needs
 Strengthen inter-sectoral collaboration and
community engagement systems
 Empower households to support PHC.
 Improve equity in access to basic health services

• The CHPS strategy takes into consideration working

with household and community to ensure the availability
of appropriate community-based services.
• Also address the barriers to access health services at the
local level.
For instance, CHO providing basic health service such as
FP, immunization, health promotion / education activities
through regular home visits and treatment of minor
ailment and organizing ANC / PNC at CHPS compound.
Improve efficiency and responsiveness to client needs

The package of CHPS intervention respond to the needs

of communities by taking the dignity of the people and
their culture in to consideration.
Also increasing accountability and performance of
health care providers and community organizations. This
is achieve through in-services training, supervision and
performance management, advocacy, community
participation etc.
 Strengthen inter-sectoral collaboration and community
engagement systems
• Strengthening of the roles of community civil society and
community –based organizations to support CHPS
implementation and client access to quality services.
• Also strengthen the capacity of sub-district level in
establishing health sector to plan and manage inter-sectorial
programmes and resources to support the programme.
• For example, GHS collaborate with GES for school health
services, local government(district assemble) for logistics
and drug supply.
 Empower households to support PHC.
Enabling people to increase control over, and to improve
their health through community mobilization,
participation and ownership of PHC by community
members. This can be accomplished by
• Encourage people to make healthy choice
• Help people make the choice with ease
• Provide information for skill development leading to positive self-
esteem
• Recognizes the capability of the client (participatory)
Components / front line actors of CHPS
Implementation
 CHPS Zone
A demarcated geographical area of up to 5000
persons or 750 households in densely populated
areas and may be co-terminous with electoral areas
where feasible. Each zone may be made up of a
town, part of a town or a group of villages or
settlements mapped for ease of planning of
itinerant services and assignment of CHOs and
CHVs.
 CHPS Compound

A CHPS Compound refers to an approved structure

consisting of a service delivery point and accommodation
complex both of which must be present.
 Community Health Officer (CHO)

• A Community Health Officer (CHO) is a trained

and oriented Community Health Nurse working in a
CHPS zone and may be assigned to live in a
Community within the zone.
Roles and responsibilities of CHO

1. Carry out regular home visits

2. Monitor growth and development of children in the
communities
3. Provide immunization services to children in the
communities
4. Provide family planning services including counseling and
refers whenever appropriate
5. organize antenatal services
6. Conduct emergency deliveries
7. Provide post natal care
8. Recognize complications in pregnancy and after delivery
and prompt referral
9. Carry out surveillance on health events in the communities
and report promptly
10. Provide primary care for simply cases like diarrhea,
simple malaria, wounds, skin infections etc
11. Provide health promotion services on specific health issues
such as personal hygiene, environmental sanitation ,
nutrition, prevention and management of sexually
transmitted infection (STI) and HIV / AIDS in the
communities.
12.CHO acts as a liaison officer between SDHMT and the community
13. Facilitate the compilation of community register
14. Supervises and monitors the performance of the TBAs in the
communities
15 Assist in mobilizing community recourses for health programmes
16. Perform any other duties assigned to him / her by the immediate
supervisor
17.Prepares an itinerary of monthly activities based on prepared action
plan by the SDHMT and CHMC by the use of C- COPE( Community –
Client, Oriented, Provider, Efficient) Services
18. Prepare and submit report on community activities regularly
 C- COPE Services
C- COPE is acronym which stand for Community –Client,
Oriented, Provider, Efficient Services
It is important method / strategy in achieving community
participation and ownership of CHPS process.
C- COPE Services involves teaching of community members
(clients / CHMC) with skills in gathering and analyzing
information (data) , developing action plan for health care
delivery in the community, implementing the action plans,
monitoring the actions and evaluation the health care delivery in
the CHPS Zone.
 Benefits of C - COPE
Develops communal spirit among community
members
Empowers all members at the levels to work as a team
Local problems are identified and solved
It helps to communicate government health policies
Help bring cordial relationship between the health
staff and the community
Increase community participation and ownership.
Criteria for selecting community health volunteers
Men and women who:
Hold leadership and membership of existing social groups in the
community
Have proven record of long term residence in the community
Have proven record of active participation in community work
Have proven record of stable character trustworthiness / honesty
Ready to work under supervision of the community leaders and the
sub-district health team
Community Health Volunteers

• Community Health Volunteers(CHVs): They

are non-salaried community members
identified and trained to support the CHOs
in a community within the CHPS zone.
Roles of the Community Health Volunteers
• Mobilize and sensitize community to take action to
manage health in the community.
• Collaborate with the CHO and support CHPS service
delivery;
• Visit, assess, and advise on environmental factors in
the home that can affect health;
• Assist the CHO in home visits, out reach services and
work at the CHPS compound
• Liaise between CHO and Community members on
health status of community;
• Support in the organization of community durbars
and disseminate health information;
• Provide first aid and refer cases to the CHO;
• Assist in compiling and updating community
register and profile.
• Carry out disease surveillance and report on
disease and health events
Community Health Management
Committee
• Community Health Management Committee (CHMC):
They are community leaders drawn from the CHPS
community with different competencies and
responsibilities who volunteer to provide community
level guidance and mobilisation for the planning and
delivery of health activities and see to the welfare of
CHOs in their community
 Roles of the CHMC

• Engage community for dialogue on CHPS

• Carry out community advocacy and diplomacy for CHPS
• Mobilize and sensitize community for health action
• Collaborate with the CHO and support the CHPS service delivery
• Engage and administratively supervise the Community Health
Volunteer to support CHPS service delivery
• Mobilize resources for CHPS service delivery
• Organize community health meetings (durbars) and provide feedback
to communities on health issues with the support of the CHO.
 Key Terms
CHPS
CHPS Zone
Functional CHPS Zones
Completed Functional CHPS Zone
Uncompleted Functional CHPS Zone
CHPS Compound
Community Health Officer (CHO)
Community Health Volunteers (CHVs)
Community Health Management Committee (CHMC)
CHPS IMPLEMENTATION MILESTONES
 Lesson objectives
By the end of the lesson, students would be able to:
 outline the six milestones of the CHPS
implementation process
explain the six milestones appropriately.
outline the frontline actors in the CHPS process
describe Organizational Layout of CHPS
explain referral system
The six milestones of the CHPS implementation process
The implementation process have been documented into six
sequential “mile stone” under the monitoring system as
follows:
1) Preliminary planning
2) Community entry
3) Creating Community Health Compounds
4) Posting CHOs to Community Health Compounds
5) Procuring essential equipment
6) Deploying volunteers
 Preliminary planning
The fundamental operational unit of CHPS is the ‘zone’, a
geographic catchment area of CHPS services for the CHO .
Starting the CHPS process involves conducting a district
assessment of manpower needs and capacities, grouping
communities into zones with defined boundaries, assessing
district equipment and assigning CHO to zones where the
programme is launched.
The numbers of CHOs and CHPS zones in an electoral area
shall be calculated based on the recommended
CHO/Population ratio of 1:750.
• This involved:
 zoning – grouping of communities in sectors.
community consultation- identification of
community leaders and sensitized them
Planning – involving the opinion leaders
(community leaders) in planning and seek for their
approval
Location of facilities- the stakeholders approve on
the location of service delivery point.
 Community entry
The district health leadership conduct community entry thus
moves the planning process from the district to the zone
level. This involves developing community health leadership
and initial participation in the programme through dialogue
with community leaders and residents.
Organized community durbar and sensitize the community
members on the CHPS concept and ask for community
participation and ownership
 Creating Community Health Compounds
Community health services require a simple facility, known
as a Community Health Compound, comprising a room for
the CHO living area and a room for a community clinic.
The community leadership utilizing volunteer labour and
locally / community resources to construct compound where
CHO live and provide health services in the community.
This collaborative activity contributes to community
ownership of CHPS.
 Procuring essential equipment
Launching Community Health Compound services
requires clinical equipment for basic primary health
care service delivery and new logistics equipment.
The DHMT in collaboration with other partners
( political leaders, NGOs, the community leadership
etc) mobilized essential logistics (preventive and
curative equipment, means of transport, recreational
facilities, etc) for the programme implementation.
Posting CHOs to Community Health Compounds
The CHO component of the programme represents the most
critical milestone in the CHPS process.
The DHMT select health personnel [ CHN, FT, Midwife]
and train or orient them in clinical services, introduce
techniques of community diplomacy, advocacy, leadership
skills, counselling methods and develop basic midwifery
skills.
 Launched by a durbar celebrating the onset of care, the
CHO is handed over to the community to assume her
resident post.
 Deploying volunteers
Depending upon the decisions of the District Health
Management Team (DHMT) and other core partners
(Community Health Committees), identify trustworthy
community members(Community –Based surveillance
volunteers (CBSVs) and provide with 6-weeks
orientation course in community health mobilization,
with particular emphasis on family planning promotion,
reproductive health, disease surveillance and hygiene
and sanitation
 Role of CHOs
• The CHO, who is a trained and oriented health professional is
required to play certain key roles in the CHPS implementation
process. Some of these are:
• Engage the CHMC to manage community health service
• Initiate process for and develop community profile in
collaboration with CHMC and CHVs
• Act as change agent for community health-seeking behaviour
• Engage community stakeholders for dialogue on CHPS
• Carry out community advocacy and diplomacy for CHPS
 CONTINUATION
• Deliver home-specific and home-relevant health services (prevention,
promotion, and minor ailment treatment)
• Treat minor ailment at the CHPS compound and refer more severe cases to
higher care level.
• Supervise supportive cadres and volunteers in technical community health
service delivery
• Deliver school health services (prevention, promotion, and minor ailment
treatment with the support of the sub-district)
• Manage and account for resources (financial and logistical) at the CHPS
compound
• Work closely with and report to the SDHT
• 
Community –Based Health Planning and
Services(CHPS) implementation steps
General Principles for CHPS
Implementation
• The general principles guiding the development and implementation of CHPS
are:
• Community participation, empowerment, ownership, gender consideration
and volunteerism
• Focus on community health needs to determine the package of CHPS services
• Task-sharing to achieve universal access
• Communities as a social and human capital for health system development
and delivery
• Health service delivered using a system approach
• CHO as a leader and community mobiliser
CHPS Policy Directives

• The CHPS policy directives cover five areas as follows:

• Duty of care and minimum package: This defines the core package of
services to be provided within the CHPS zone by the CHO and CHV.
The package focuses predominantly on maternal and child health
(MCH) and nutrition services. Coordination and linkages with private
health facilities in the CHPS zone is also emphasised.
• Human resources for CHPS: It clarifies who a CHO is and determines
the CHO-to-population ratio. It directs that a system for career
progression be developed and incentive schemes instituted. It also
identifies the essential role of the CHVs.
• Infrastructure and equipment for CHPS: It defines standards for a CHPS
compound and the accompanying list of equipment and furnishings and
directs that all CHPS compound construction should comply with standards.
Guidance for completing ongoing projects is provided. The directive also
provides that the establishment of CHPS zones and location of CHPS
compounds should be determined by Metropolitan, Municipal and District
Assemblies (MMDAs) and all land for construction should be documented and
sealed at the Land Title Registry. Rural and underserved areas per the policy
directive will be prioritised for CHPS construction and guidance is also
provided for urban CHPS.
• Financing: It directs that all services delivered in a CHPS compound
shall be free and assigns government the primary responsibility for
financing.
• Supervision, monitoring, and evaluation: The policy directive
provides for the hierarchy of supervision, monitoring and evaluation.
It indicates that the officer in charge of the sub-district shall supervise
the work of the CHO, with technical support from the District Health
Management Team (DHMT). It also provides that, the CHMCs shall
monitor and evaluate services as part of participatory development
through the use of the Community Scorecard to provide real-time
feedback to the CHO and health managers.
 CHPS Implementation Steps
• A key feature of CHPS is a community-based service delivery that focuses on improved
partnership with households, community leaders and social groups – addressing the demand
side of service provision and recognizing the fact that households are the primary producers
of health.
• A CHO engages each community within the zone (catchment area) in micro planning of
health activities, sometimes termed “community decision making system.”
• The CHPS organisational change process relies upon community resources for construction,
labour, service delivery, and programme oversight including monitoring and evaluation.
• As such, it is a national mobilisation of grass-root action and leadership in health service
delivery.
• The implementation of the CHPS strategy demands systematic and joint planning and
execution by the DHMT, the SDHT, and the community leadership as well as the citizenry at
large.
• Once the decision is taken by the DHMTs and the communities to establish CHPS zones, the
following ‘milestones’ are essential to the establishment of a fully functional CHPS zone
within a sub-district.
 Six Milestones of CHPS
• Milestones:
• Detailed plan created: In this milestone, situational analysis is conducted and
communities are mapped in consultation with the community leadership. Also, at this
stage, the CHPS coverage plan is developed to guide the district in the implementation
of CHPS.
• Community entry conducted: The second stage involves community entry, which
encompasses five major activities. These include; dialogue with community leadership,
organising community information or sensitisation durbars, selection and training of
CHOs, selection, approval and orientation of CHMC and compiling community profile.
• Community Health Compound (CHC) operationalised: This is the site where the CHO
will live and provide services. This phase includes securing funds for building or
renovating a structure to serve as the CHC, selecting a site for the CHC that is
acceptable and easily accessible to the entire community and mobilising communal
labour for CHC construction. The most essential aspect of this milestone is having the
CHC constructed or available.
• Essential equipment supplied: In this phase, supplies, medicines, equipment and
furniture are mobilised for service delivery. The CHO also requires means of
transport to conduct door-to-door service delivery which should also be mobilised
at this stage.
• Community Health Officer (CHO) posted: This phase includes the training and
deployment of the CHO to the CHPS zone and holding a durbar to introduce him/her
to the community members. It also involves formal launching of the CHPS zone.
• Community Health Volunteers (CHVs) deployed: This phase consists of selecting
and training the community health volunteers, convening a durbar to introduce
them, holding training for CHMCs to oversee the work of CHVs and the procurement
and distribution of their supplies.
• Embedded in the six milestones stated above are 15 implementation steps that
guides in the completion of these six CHPS milestones. Under each step are key
activities to be carried out.
The 15 implementation steps in the CHPS process or activity sequence.

For a successful implementation of CHPS , there is the need to

performed some activities . These activities has been group in
to 15 implementation stages / steps.
15 implementation stages / steps
Planning and demarcation of a CHPS zone:
• Situation analysis and problem identification at the DHMT level
• Consultation with MMDAs: i.e. The Chief Executive of the MMDA and the Social Services
Sub-Committee
• Zoning of communities in the district
• District CHPS Scale-up Plan in line with electoral areas
 Consult and raise awareness of CHPS
• Consultation and sensitisation of health workers
Dialogue with community leadership
• Identify contact persons e.g. assembly member
• Meet with community leadership
• Sensitise the chief and his elders highlighting key support areas from the chief and
community (e.g. community durbar, workspace, land etc)
Organise community information durbar with communities in the CHPS zone
• Participation by all communities making up the zone
• Sensitise community members on CHPS
• Address questions and concerns of community members
• Discuss site selection and approval for construction of CHPS compound with community members
• Roles and responsibilities of stakeholders including community members
Select and train staff as CHOs
• Health staff such as CHNs, midwives and Enrol Nurses are selected and trained as CHOs
• Discuss with each CHO the CHPS zone they will be assigned to
 Select, approve and orient CHMC
• Selection of CHMC members based on the criteria outlined in the CHPS implementation guideline
• Durbar for approval of CHMC
• Orientation of CHMC
Compile community profile
• Compilation of community profile: consisting information on geographic and demographic
characteristics, settlement patterns, existing human habitation and health features and
facilities
• Read any available literature about the communities making the zone especially where the
compound will be sited
• Ask individuals in the community about the history, norms, taboos, secret places, occupations,
etc.
• Conduct a transect walk to identify important landmarks including schools, churches, mosque,
chief palace, market, etc.
• Inform the opinion leaders on the necessity and time needed to register community members
• Register community members by community and by household
• Summarise the results to obtain population by community, number of households by
community, etc.
Construct/ operationalise compound
• When planning for the construction of a new CHPS compound, the DHMT shall plan an initial
meeting with all the community leaders residing in the CHPS zone. This is often done during the
dialogue meeting with the Chief and elders during the sensitisation durbar
• Procurement (construction, renovation, hiring, renting, or rehabilitation) of CHC for CHO residence

Provide CHPS logistics

• Motorbike for CHOs and bicycle for volunteers
• Relevant registers and reporting formats
• Home visiting bags with contents
• Provide sufficient supplies, medicines, equipment, furniture, and transport to CHPS zone for
service provision 
Organise durbar to launch activities of the CHPS zone
• Organise community information durbar to formally launch CHPS in the community
• Formal introduction of CHOs to the community at the durbar
Select CHVs
• Selection of CHVs (refer to implementation guidelines for selection criteria)
Approve CHV selection
• Host durbar to finalize the selection and gain approval of CHVs from community and community
leadership 
Train CHVs
• Train CHVs based on the training content spelt out in section “Step 13: Train CHVs” of the CHPS
implementation guideline 
Procure logistics, equipment and volunteer supplies
• Mobilisation of logistics and equipping the volunteers 
Launch the CHPS zone
• Launch the CHPS zone
• Introduce CHMC, CHVs and CHO during the durbar
• Introduce security guard for the compound, etc.
• 
 1. Strategic Planning
This is an important instrument which guides the DHMT in the development of
a relevant district health service.
In this stage, the District Director of Health Services and his or her
team(DHMT) reflect on the performance of the health sector, with
the full participation of the District Chief Executive. Together they
carry out a situational analysis / SWOT analysis, design the CHPS
program based on policy.
Identify priority communities , consult and dialogue with community leaders
for their inputs into the design.
 Situation Analysis

A situation analysis is an assessment of current health situation

and is fundamental to designing and updating the required
policies, strategies and plans. ( national, local)
A strong situation analysis is not just a collection of facts
describing the epidemiology, demography and health status of
the population. Instead, it should be comprehensive,
encompassing the full range of current and potential future heath
issues and their determinants and then compared with the
expectations and needs of the institution.
Conducting Situational Analysis - CHPS

The essential and key step in implementing Community-

based Health Planning and Services for all districts is
conducting a situational analysis of service delivery
coverage as well as an appraisal of the status of CHPS
implementation in the sub-district.
This is the process by which the DHMT carries out a critical
examination of its operations in the delivery of Primary Health
Care Services to the people of the district with the view of:
Assessing its capabilities
Identifying the challenges, and
Developing a new and more relevant program of action.
By this process the DHMT constitutes itself into a special
review team made up of the DDHS, the Senior Medical
Officer / medical superintendent in charge of the District
Hospital, the Senior Public Health Nurse, the Disease Control
Officer, the Medical Assistant and the Sub-District Heads
 SWOT Analysis
SWOT analysis is another method / tool under the situation
analysis that examines the Strengths and weaknesses of
institution ( internal environment) as well as the Opportunities
and Treats within the institution (external environment)
In fact a SWOT can be used for any planning or analysis
activity which could impact future finance, planning and
management decisions. It can enable you (the public health &
clinical staff) to carry out a more comprehensive analysis.
 Definitions of SWOT
 Strengths – Factors that are likely to have a positive effect on (or
be an enabler to) achieving the facility’s objective
 Weaknesses – Factors that are likely to have a negative effect on
(or be a barrier to) achieving the facility’s objectives
 Opportunities – External Factors that are likely to have a positive
effect on achieving or exceeding the facility’s objectives, or goals
not previously considered
 Threats – External Factors and conditions that are likely to have a
negative effect on achieving the facility’s objectives, or making the
objective redundant or un-achievable.
Possible or frequently asked questions
 Strengths
What do we do well?
What advantages do we have?
What relevant resources do we have access to?
What do others see as our strengths?
 Weakness
 What aren’t we doing well?
 What can we improve?
 What should we avoid?
Possible or frequently asked questions cont’d
 Opportunities
 Where are good opportunities facing us?
 What trends might be helpful to observe?
 Treats
 What obstacles do we face?
 Is technology changing faster than we are adopting
to the changes?
 2. ACTION PLANNING
• This is where the DHMT in collaboration with key
stakeholders zones the catchment area (identified
communities) and strategically locates the CHPS
Compound to the benefit of the inhabitants. CHPS zones
should be coterminous with electoral as much as possible.
The numbers of CHOs and CHPS zones in an electoral area
shall be calculated based on the recommended
CHO/Population ratio of 1:750.
 Criteria for selecting communities for CHPS
zone.
Prevalence of high fertility, morbidity and mortality
Prevalence of poverty in the area
Prevalence of social, religious and traditional beliefs
that hinder health care
High illiteracy particular among women
Epidemic and other preventable disease conditions
rate
Accessibility of health services
Estimating population to be covered by CHO
• Home visits = 5 a day
• 5 days a week But working at 50% ~ 3 days/week
• 4 weeks a month
• 10 months a year =500 households  
• To be able to make 4 visits to each household in a year = 500/4 =
125 hshlds / CHO
• Average # of 6 people per household = 750 persons per CHO
• 2 CHOs per electoral area = 1,500 persons per CHPS zone
 3. Programmatic Planning
In this stage, the District
Director of Health Services
and the Sub-district Head and
community leaders conduct a
series of community
information durbars, select the
CHOs, the Community Health
Management Committees and
compile a community profile.
 4. Consultation and sensitization of health
workers
In this stage, the District
Director of Health Services
and the DHMT organized
various workshops to prepare
/ sensitized health workers
for the CHPS strategy and the
roles expected of them
 5. Consultation with political leadership
The health services
leadership consulate the
political
leadership(DCE, MCE )
about the programme
and seek for support .
 6. Consultation with community leadership.

The health services

leadership consulate
traditional leaders of the
community to accept the
CHPS concept and commit
themselves to support it
(participation and
ownership).
Also construct the CHPS
compound by the used of
locally available resources.
 7. Community information durbar

The health team with

collaboration with the
stakeholders organized
community durbar and
present the concept of the
programme to the
community members and
specified their role and
responsibilities. This is done
to seek for the acceptance
and support
8.Selection and Training of Community Health Officer (CHO)

Identified health personnel

(Community Health Nurses or
Disease Control Assistants (FTs)
or Midwives) are retrain / orient
on advocacy, mobilization,
leadership skills, CHPS policy,
health promotion and prevention,
curative and rehabilitation, case
detection / surveillance, referrals
etc
 9. Selection and orientation of Community
Health management Committee
• In this stage, community leaders in collaboration with DHMT
identify and train trustworthy community members to assist in
community health activities
Membership of community health committee comprises:
A representative from each of the communities that make up the
cluster (Zone)
A representative of the unit committee.
 the district assemble member(s) for the area
A representative of the traditional / area council
 a representative from any recognized group within the zone.
10.Formal launching of the CHO
The DHMT in collaboration with community leadership
organized a durbar and officially present the CHO to the
chiefs and community members within the catchment
area / zone.
12. Durbar for the approval of Volunteers ( CHMCs and CHVs)

This is where a durbar is

organized to officially
present the CHMC and
CHV to the chiefs and the
community members
within the catchment area
for their acceptance and
approval for training.
13.Training of Community Health Volunteers

The DHMT trained the

CHVs on their job
description, duties and
responsibilities.
Also they are sensitized on
CHPs concept and
Volunteer Systems in
CHPS (volunteerism).
 14.Mobilization of Logistics
The DHMT in collaboration with District assemble and NGOs
mobilized logistics.
 Service Delivery Logistics
• Cold Chain equipment;
• Service delivery consumables;
• Working gear (wellington boot, raincoat, torch light etc);
• Communication equipment (two way radio or mobile phones,
etc.);
• Personal Digital Assistants (PDAs) for data collection.
Mobility / Transport Logistics
• Motorcycle for the CHO;
• Bicycles for the Volunteers in each community within the
zone
• And where necessary, the following:
• Tricycles, tiller ambulance, tractor ambulance, motorboat
Comfort or recreational Logistics
• Accommodation; newly constructed, renovated, or rented.
• Consumer durables: bed, furniture, TV, radio set, kitchen
ware, etc.
15. Formal launching of the volunteers durbar
• The DHMT in collaboration with
Community opinion leaders
organized final community durbar
and introduced all personnel involve
in health service delivery within the
zone.
• Emphasised on the support for the
CHO, the level of services for each of
the personnel (CHO, CHMC and
CHVs) and community support –
(community ownership and
participation)
REFERRAL SYSTEM
By the end of the lesson, students would be able to:
explain referral system appropriately.
describe referral guidelines
identify the roles of members / stakeholders during
referral.
outline challenges / factors influencing referral
explain feedback and follow-up in referral system.
• Referral is a key component of service delivery aim at providing
quality health care to clients. It involves coordination, cooperation as
well as information sharing between the various service delivery
points.
• Effective referral requires proper judgment guided by checklists,
protocols and guidelines, skilled personnel, clear communication and
timely transport to ensure that a patient receives optimal care at each
level of the health system according to the patient need, vulnerability,
and disease severity
CONT

Each services delivery point shall establish with

the collaboration of the CHMC, an appropriate
referral system for clients needing higher level
care.
The referral system shall ensure that there is
continuation of care from referral point to
receiving point.
TYPES OF REFERRALS
• External – this is referral outside the referred facility
( one facility to another facility within the same
country)
• Internal – this is referral within the health facility ( one
department to anther department, within a department
and one unit to another unit or a department)
• International - this is referral outside the referred
county ( from one country to another)
CLASSIFICATIONS O REFERRAL
Vertical – referral of client from lower to higher level or vise versa
Horizontal –referral of client from one facility to another facility on the same
level with capability (eg from one district hospital to another district hospital.
Internal – this is usually within the facility from one health provider to another.

RATIONAL FOR REFERRING CLIENTS PROMPTLY AND

APPROPRIATELY.

1. Referring clients / patients promptly saves life, resources and time

2. For continuity of care .
• Referring facility role:
– Clear judgment on health status of patient
– Complete referral form
– Document the reason for the referral in a register
– Advise patient to go to receiving facility
– Activate emergency transport arrangements for the patient if so required
– Receiving facility is informed ahead of arrival of patient
• Receiving facility role:
– Prioritize referred patient
– Retain referral form
– Register referred patient
– Feedback on referred case
Roles of the family / community members

Provide financial and moral support

Mobilization of transport
Accompany the sick person to the receiving facility
Provide basic needs and support client at hospital
Supporting clients children if any
Support client to recover fully when discharged back to the
community.
Feedback and follow -up
Feedback shall be sent to the referring facility
The attending practitioner / clinician at the receiving
( referred) facility shall, where possible refer patients back to
the referring facility for continuation of management
The attending practitioner / clinician at the
receiving(referred) facility must clearly specify on the
feedback form, details of ongoing management or further
therapy required
Challenges / factors influencing referral
Government Policies
Lack of connection between different level of the referrals
Inadequate transport system
Poor rood net work
Inadequate / insufficient knowledge on referral principles
Self –referential and bypassing the referral system
Community mobilization and participation
 Lesson objectives
• By the end of the lesson, students will be able to:
explain community mobilization and participation
list benefits and challenges of community mobilization and
participation
justify community mobilization tools and Approaches
list Participatory Learning Action (PLA) tools and technics
and explain them correctly
develop Community Health Action Plan (CHAP)
appropriately
explain the benefits and challenges of CHPS programme
 Community Mobilization
Is the process of engaging community(ies) to identify community
priorities, resources, needs and solutions in such a way as to promote
representative participation, good governance, accountability and
peaceful change.
Good Governance- the process of decision-marking and how those
decision are implemented.
Accountability- the process of sharing information about actions or
intentions. Eg those individuals elected / honour their commitment /
responsibilities to lead developmental projects in the community are
accountable to members of the community.
 Community Mobilization con’t
Community Mobilization is a capacity building process
through which individuals, groups or organizations plan,
carry out and evaluate activities on a participatory and
sustained basis to improve their health and other needs,
either on their own or stimulated by others.
What does it mean to mobilized community
Mobilizing community means engaging all sectors of the
defined community in a community wide plan.
This involves identifying existing community groups, engaging
formal and informal leaders and involving service
organizations active in the community.
Key Task involved in Community Mobilization
Analyse the capacity of communities
Develop an on-going dialogue with community members
Create an environment in which individuals can empower
themselves to address their own and their community’s health needs
Promote community members’ participation
Work in partnership with community members ( include them at
every stage)
Assist in linking communities with external resources
Commit enough time to work with communities, or with a partner
who works with them.
 Community mobilization process / steps
Establish a community mobilization team
Train team on community mobilization approaches
Identify relevant stakeholders and share roles and
responsibilities with them
Meet with stakeholders to discuss health issue
Develop a community mobilization plan
Identify and mobilise resources from stakeholders
Implement your mobilization plan
 Principles of community mobilization
Community mobilization is most achieved when participation is
maximized / increased and this can be attained by applying principles.
Some of these principles are:
Welcome wide involvement even from who disagree with you
Facilitation of discussion, providing opportunities for everyone to
have their say
Work together on issues everyone can agree on, look for points of
consensus
Avoid top-down approaches of decision making
 Community participation
Community participation is the active involvement of
community members in analysis, decision-making, planning,
and programme implementation.
Community participation is the process by which individuals,
families assume responsibility in promoting their own health
and welfare. The community should be actively involved in the
planning, organization, implementation, and management of all
programmes. They should help with the infrastructure,
personnel, and maintenance of the health facilities. Residents
and health providers need to work together in partnership to seek
solutions to the complex problems facing communities today
Community mobilization and participation
Community mobilization and participation is a process by
which communities are motivated to bring together human,
material or financial resources to take action to improve
their state of development and well-being
 Benefits of community mobilization and participation
Develops communal spirit among community members
Enable communities to determine their own development
Empowers all members at the levels to work as a team
Build trust within communities so they can work together effectively
Build civil society – capacity of community to work with government and other
sectors.
Local problems are identified and solved
It helps to communicate government health policies
Help bring cordial relationship between the health staff and the community
Increase community participation and ownership.
Challenges of community mobilization and
participation
May create tension for the organization,
including deciding how much authority will
be given to activist groups associated with
the organization to decide the agenda
May create backlash/tension as a result of
a more direct action agenda
Requires leadership skills that may not
readily exist within the organization
Challenges of community mobilization and
participation con’t
Requires expanded personal commitment
from people doing the work, i.e. walking
the talk
Can open the door to new constituencies/communities; is the
organization committed to doing whatever
it takes (e.g. dealing with institutional racism)?
Requires an intense commitment of resources and leadership;
community mobilization may be perceived as less important than
direct services, requiring consensus or buy-in on priorities
Challenges of community mobilization and participation con’t

May bring up internal tension because a community mobilization

agenda can challenge the status-quo mindset of the organization.
Challenges the organization to decide what kind of partnership it
wants in working with at the community level ; may require new
training program for women and men working as allies.
Challenges the organization to develop new ways of working with
youth as agents of change instead of recipients of services
Community mobilization tools and
Approaches

Participatory Learning Action (PLA)

Community Health Action Plan (CHAP)
 Participatory Learning Action (PLA)
• Participatory Learning Action (PLA) are methods and
approaches to analyse, share and enhance their (community)
knowledge of life and conditions and to plan, prioritize, act,
monitor and evaluate.
• It combines visual methods with interviewing techniques and
is intended to facilitate a process of collective analysis and
learning.
• PLA are methods and approaches that enable local people to analyse,
share and enhance their knowledge of life and conditions and to plan,
prioritise, act, monitor and evaluate their activities. It is participatory
because it involves transparent communication with community
members.
• It is also a learning process because community members are directly
involved in the process of identifying the issues and concerns.
• It also involves immediately action to find solutions because the
various groups come together to find the solutions. Learning from and
with community members is therefore a core principle of PLA.
 Participatory Learning Action (PLA) con’t
It is an effective, low-cost, empowering, participatory method
of gathering qualitative and semi structured information
(beliefs and behaviours)
It is used in identifying needs, planning, monitory or
evaluating projects and programmes.
It enables local people to share their perceptions and identify,
prioritise and appraise issues from their knowledge of local
conditions.
Key persons used in application of PLA in CHPS
implementation
• Chiefs and elders
• Assembly members
• Unit committee chairperson
• Social or organised groups
• CHCs and CHVs
• TBAs & traditional healers
• Opinion leaders
 How is it conducted?
Participatory Learning Action (PLA) is effectively
conducted by using PLA tools and technics.
Participatory Learning Action (PLA) tools are grouped in to
two major categories.
Namely:
Information gathering tools and
Analytical tools
 Information gathering tools
Transect walks
Community mapping
Daily activities
Seasonal calendar
Time lines
Brain storming
Role play
Focus group discussion
Semi structured interviews
 Analytical tools
• Pair wise ranking
• Matrix
• Venn diagram
• Pie chart
Application of PLA in CHPS
implementation
• PLA can be used at any stage of CHPS implementation. It is relevant in
many respect some of which are stated below:
• It can facilitate effective “community entry”
• PLA can be used to mobilse communities and increase their awareness
and participation in quality health service delivery by CHPS.
• It helps to identify local resources and social groups e.g. mother support
groups, traditional leaders, youth groups vulnerable groups etc.
• It can be used to analyse the status of resources and relationships among
the groups in the communities
 Transect walk

It is purposeful walk with key informants through a

community or an area of interest while observing,
listening and asking questions about the community.
Transect walks are a type of mapping activity but they
involve actually walking a cross an area with a
community member/ group of community members,
observing, asking questions and listening as you go.
The information gathered is then represented visually in a transect
sketch / diagram for further analysis.
Transect sketch presentation of information gathered
Community mapping
• A map is a very useful tool for a CHPS zone as it displays important
features of the community for the information of all stakeholders. It
shows the most important landmarks and demarcations
• Community mapping is a method, which visualizes the key
resources, infrastructure, people and other means in defined area.
• Also it provides deeper insight on what resources or infrastructure
well provided for and which are not and should be improved.
 Community mapping
• Mapping activities allow the community to show and talk
about how they see the area they live, the resources / facilities
available and what is important to them in their environment.
• In preparing for home visit, it is important to map out areas
to be visited. This will enable the CHO to plan and cover the
entire CHPS zone taking into consideration areas that require
special attention. Details on how the map can help the CHO
include:
• Identify and mobilise appropriate resources and
• Focus health service to meet the needs of the specific area
• Plan visits in such a way that all areas in the CHPS zone are
covered
• Ensure easy movement and identification of households
• Assess the distances and identify obstacles in the terrain
• Highlight areas of diseases of public health importance e.g.
cholera, TB etc
Community mapping
 Daily activities

Daily activities is used to map out key activities in the

community
The daily activity shows how community members spend a
typical day and how much time they spend on these activities.
Daily activity can focus on areas such as domestic chores and
tasks outside the home eg. Farming , marketing etc.
• Daily Activity is used to map out all of the activities in the typical day of
community members e.g. males, females or adolescents in the community.
The daily activity shows how community members spend a typical day and
how much time they spend on these activities.
• The purpose is to help the CHO to plan health activities without conflicting
with community activities. Daily activity can focus on special issues such as:
• Domestic chores
• Tasks outside the home such as farming and marketing
• In the case of a CHO, a typical day at the health center would include
outreach services, home visits etc
Daily activities
Seasonal Calendar

• Seasonal calendar is to identify cycles of seasonal

activities that occur in a community It helps the CHO to
identify issues such as migration, farm activities, rainfall
pattern, temperature changes, disease burden etc.
• A seasonal calendar helps the CHO to identify seasonal
activities for planning and implementation of
community activities. An example of this is community
activities requiring labour.
Timelines

• Timeline is a time-related data gathering tools that

links dates with historical events. It is most commonly
used to examine a sequence of events over many
years.
• It can also be used to describe a community’s history,
political events, major disease outbreaks, changes in
natural resources and development of infrastructure
among others
Sample Timelines of Kojokrom Community
 Semi structured interviews
• Semi-structured interviews are conducted with fairly open
framework which allow for focused conversation.
• It is a qualitative method of inquiry that combines a pre-
determined set of open questions.
• It is used to understand how interventions work and how
they could be improved
 Venn Diagram
Venn Diagram is tool used to analyse the relationship
among institutions, organizations ( both formal and
informal) or stakeholders in CHPS zone.
Through this diagram the key stakeholders are
visualized and related to each other on importance
and frequency of contact.
This method is best used with a group rather than
individuals
Venn Diagram
 Pair wise ranking

Pair wise ranking/ scoring activities is a tool that provide a way

for community members to weigh up / rate priorities items or
issues either relative to one another or according to criteria.
It is conducted with a large group of people (more than ten) to
help them compare several items or issues relating to one
another by comparing two items at a time. It gives community
members the opportunity to compare every other item in the
group to come out with their priority
It is used to compare several items or needs of a community, rank
and prioritize. This is usually done with a large groups of people (
more than ten)
Sample Pair wise ranking of Chiraa community
Pair wise ranking
 Matrix
• This technique is often used in establishing relationships between needs and
solutions or diseases and their causes. The most typical application of this tool
is to find out the relationship between diseases seen in the community and the
community’s perception about the causes.
• In developing the matrix, the PLA facilitator draws a grid on the ground, with
the diseases listed on the left side and the causes listed across the top. Local
objects such as leaves, empty tins, stones, and sticks among others can be used
as symbols to represent diseases or problems identified by the community.
• This technique is often used in establishing relationship between needs and
solutions or diseases and their causes.
• The most typical application of this tool is to find the relation between diseases
seen in the community and the community’s perception about the cause.
Sample Matrix of Ankase community
 Pie Chart
It is generally known as a circular chart divided into sectors
illustrating relative magnitude, frequency or percentages.
In CHPS implementation there are several applications of
this tool. The most typical usage is to analyse expenditure
pattern in community.
The CHO uses this tool to assess areas that community
members focus their resources / finances and how they can
contribute to CHPS in cash and or in kind.
Pie Chart
 Community Health Action Plan (CHAP)

• Community Health Action Plan (CHAP) is a process where a

community (group) passes through a process which help
them to develop a plan on a participatory way which has the
support of everybody in the community/group and where
members commit themselves toward implementing activity.
The planning process has both element of mid- term and
long- term( operation planning)
• It is a tool / document used to develop effective community
health strategies.
• CHAP is an action plan developed by community members in a
participatory manner with the support of the CHO to undertake
community related activities that will help improve the health status
of community members.
• The action plan indicates what communities would like to achieve in
terms of their health within a specified period. CHAP engages
community members from planning to evaluation of health
programmes and encourages effective community participation in
health care delivery, which is the cornerstone of CHPS
implementation.
 Community Health Action Plan (CHAP)

• The goal of community action plan is to develop plans of action for

addressing those health issues(problems) that have been identified as
priorities by the community through the community health
assessment (CHA) process.
• The key to developing successful plans is to begin with health
priorities, used evidence- based interventions and plan realistic
evaluation method / action plan.
• CHAP highlights the planning component and empowers community
members to undertake community-led initiatives because
communities are no longer seen as consumers but active partners in
health care delivery
 CHAP con’t

• For each issues (problems) the assigned work group should

look at the community data, think through the factors that
contribute to the issue, identify factors that could perpetuate it
and ways /activities to address the issues.
• The groups should consist of representatives of community
residents, agencies / organizations with special expertise or
interest in the issue, and / or those affected by the issue. Eg.
Law enforcement officers, social workers, chiefs, GHS staff,
GES staff etc.
Indicators for developing Community Health Action Plan (CHAP)
The participative planning process basically consist of five steps:
i. Objective / victory : what are our perceptive and wishes for the future?
ii. SWOT analysis: what are the strengths, weakness, opportunities of the
community and the threats /dangers that can hinder community projects.
iii. Commitment / Goal: what are the project goals we would like to achieve?
What are the elements needed and what are the conditions to fulfill this
project.
iv. Strategic directions and key activities: Which strategies and key activities do
we implement to accomplish our vision?
v. Implementation: What? How and When? – what are we implementing, how
are we doing it and at what time.
A Flow chart depicting the process of developing CHAP
 Community Health Action Plan (CHAP)

Problem Causes / Activity Person (s) Ev

predisposing (recommendation responsible Budget Durat alu
objectives

factors item Qua Unit freq Total ion ati

ntity cost uenc Cost on
y

Teenage  Peer  Organize  CHO Staff 5 100 3 1500 Jan-

pregnancy pressure community  Assemble Jun
 Media durbar and man I E 150 5 3 2250
influence educate populace  SHEP Co- &C
 Poverty on courses, ordinator. mate
 Poor effects and etc rials
parental preventive
care measures
 etc
 Schedule

Target/Implementing
Resources Person in
Community/Overall Time Main Activities MOV Remarks
Required Charge
Frame
Sept.13 Oct.13 Nov.13

Target 1:
                       
Advocate for
the construction of culvert on
road leading to CHPS
compound. Daworo Chief 1. Meeting
1. Organize a
Time Assembly member attendance book
community
Implementing communities Minutes CHMC 2. Minutes
wide meeting
All CHPS communities       book Chairman of meeting

Overall Time frame

Sept.13 to Nov.13

                       

1.Copy of
support
1. Make follow-up to
Money for CHMC chairman letter
DA on application for
transport Assembly member 2. Documented
support
Time feedback on follow-
 
up

         

Pick-axes
3.Fetch sand and
Pans Youth leader 1. No. of trips
water to support
Shovels CHMC chairman of stones and sand
construction
Communal labor to fetch stones, Water Assembly member ;tank with water
of culvert        
sand, and water containers/tank

 
Benefits of CHAP

• Strengthens community participation in all health

activities
• Communities are focused on how to improve their own
health without relying on external or donor support
• Promote ownership and sustainability of health
programs as communities play the lead role in
identifying, planning, implementing and monitoring of
agreed health activities
Application of CHAP

• CHAP can be used to solve various community health issues. For

example;
• Establishing Community Emergency Transport System
• Assessing the health service and score for the community scorecard
• Supporting CHO with water and providing security etc.
• Construction of additional facilities at the CHPS zone
• Improving health indicators such as Antenatal, skill delivery,
immunization, male involvement etc.
Benefits of using the CHPS process
1. Improved delivery of preventive and curative health services
2. Early treatment and referral
3. Reduction in infant and child morbidity and mortality
4. Reduction in vaccine preventable diseases
5. Improvement in sanitation due to regular health education
6. Reduction in growth rate due to acceptance and use of modern
contraception
 Challenges of CHPS
• Inadequate facilities
• Inadequate service delivery equipment
• Lack of clear understanding of the CHPS concept
• Refusal of staff to CHPS Compound
• Inadequate fund allocation
• Limited operation of CHOs at CHPS compounds.