Community health workers in Ghana: the need for greater policy attention

Baatiema, Leonard; Sumah, Anthony Mwinkaara; Tang, Prosper Naazumah; Ganle, John Kuumuori

al communities in Bolgatanga, Kassena Nankana and Bawku West districts of Ghana, Oxfam has trained and evaluated the work of some 150 TBAs. 30 51 The evidence from Oxfam's work has shown positive results. In each of the communities where Oxfam trained and worked with TBAs, the number of women being referred by TBAs to clinics and hospitals for potentially life-saving care doubled. 51 Maternal mortality has similarly reduced by 7%. 51 Further, between 2005 and 2007, one of the authors ( JKG) was involved in a community-based pilot health project in 30 communities in Nadowli District, Upper West Region, Ghana. 30 This project was implemented by World Vision Ghana in partnership with Ghana Health Services. The project trained CBSVs and TBAs to perform a number of tasks, including recording births and deaths, and reporting disease outbreaks. 30 Several TBAs also got trained to detect danger signs during pregnancy and labour and to make quick referral of pregnant women to health facilities to receive skilled care. 30 The TBAs were all provided basic consumables such as hand gloves, hand sanitisers, new packs of cutting blades and kerosene lanterns (to be used in the night when there is no electricity). The main aim of the project was to improve TBAs' skills and resource them adequately to conduct normal deliveries, particularly in hard-to-reach rural communities. In mid-2007, an initial evaluation was done. The evaluation results showed that antenatal care attendance in some communities had increased twofold (ie, 41% in 2005 to 85% in 2007). 30 Qualitative interviews with women and TBAs suggested that many TBAs who received the training and essential consumables actively encouraged and referred pregnant women to healthcare facilities. 30 Also, among women who delivered at home with TBAs, infections resulting from the use of bare hands and other unhygienic practices by TBAs (such as the same blade being used to sever the umbilical cords of two babies) during labour were reported to have reduced. The women and TBAs who participated in the interviews largely attributed the increase in the number of referrals to health facilities for skilled delivery and a reduction in infections during labour to the training TBAs received and the supply of hand gloves, hand sanitisers and new blades. 30 In fact, these positive results from Ghana are supported by evidence from other low income contexts. [52] [53] [54] [55] [56] Notwithstanding these evidences, TBAs' activities in maternal healthcare until now are still surrounded with controversies because the WHO official position only permits TBAs to make referrals and not conduct home deliveries. 30 51 However, based on this evidence from the Upper East Region and the fact that in Ghana only 55% of births are attended to by a skilled attendant (defined here as a doctor, nurse or midwife), and 30% by TBAs, 30 we consider the WHO position on TBAs as untenable in LMICs such as Ghana where the capacity to provide skilled and supervised delivery is limited.