What works? What fails?
FINDINGS FROM THE NAVRONGO COMMUNITY HEALTH AND FAMILY PLANNING PROJECT

Vol. 1, No. 3, September 2001 Navrongo Health Research Centre

ROLE OF RESEARCH IN THE NAVRONGO EXPERIMENT

Introduction

Launched in 1994 with the aim of finding ways of addressing the expressed health needs of rural Ghanaians, the Community Health and Family Planning (CHFP) Project or The Navrongo Experiment, is in line with Ministry of Health (MOH) policy guidelines for decentralising accessibility to Primary Health Care (PHC). Its ultimate aim is to test hypotheses about fertility and mortality reduction. The project design was based on the premise that existing idle human and material resources of the MOH can be mobilised in ways that improve accessibility, quality, and range of community health services. The project was also designed to test hypotheses about the health and family planning impact of mobilizing traditional leadership, social networks, and volunteerism for the promotion, delivery, and supervision of PHC.

Why Navrongo?

Navrongo is situated in the Kassena-Nankana District in northern Ghana. The district, with about 142,000 residents in 14,500 compounds, is an essentially agrarian traditional locality where mortality is high and fertility remained unchanged prior to project intervention. Baseline contraceptive use in the district was less than four (4) per cent and fertility about five (5) per cent. Immunization rates were low, and infant mortality was 120 per 1000 live births. Possibly as a consequence of high mortality, customs emphasising the importance of large family size deeply affect the social response to services, requiring careful strategic attention in the design of reproductive health care. Survey results suggest that couples welcome family planning services that emphasise childspacing, but qualitative research shows that many men fear that the introduction of family planning and reproductive health care for women will diminish their status as heads of households. These are characteristics of a typical African rural community. Much is known about improve-ments in health status and survival that accompany economic development and social change; less is known about how to induce and sustain the health transition in the absence of economic development and social change. This is how Kassena-Nankana District became an ideal site for determining whether improvements in health can be attained and sustained in a traditional African setting using realistic interventions and resources without waiting for economic development or social change to occur first. The demanding features of the setting—the challenging context for developing health care and the daunting prospects for improving reproductive health care coverage—make Navrongo an ideal setting for community health research. If the health and family planning needs of this locality can be met, then it is arguable that success is possible anywhere.

Although the setting makes The Navrongo Experiment an important policy initiative, research resources of the Navrongo Health Research Centre (NHRC) greatly expand the contribution of the experiment to policy. The core research resource of the NHRC is the district-wide Navrongo Demographic Surveillance System (NDSS) that records all vital events and ensures that the demographic impact of health services can be subjected to systematic trial. The NDSS defines household relationships, permitting the systematic storage and retrieval of information about individuals, compounds, or treatments over time for any special study in Kassena-Nankana District. The NDSS represents the relational structure for all other data sets collected at NHRC. A Panel Survey System (PSS) has also been instituted that monitors individual characteristics, preferences, and reproductive health status over time. Panel instruments record family planning knowledge, contraceptive use, and intentions to use in the future. Shortly before the project was launched a sample of about 1,860 compounds was designated where all resident women ages 15-49 were interviewed in annual surveys about reproductive beliefs, motives, and preferences.

Research Programme

Social research is conducted in conjunction with quantitative research systems. This qualitative research programme enables the project to get practical community advice on what works best and what does not work in this setting. Various features of the NHRC approach to research enhance the credibility of its results for policy: i) Results are based on the observation of a large population. Results cannot be dismissed as something that chance could produce; ii) Results are based on continuous population surveillance data that are free of recall biases. Standard procedures for checking on the completeness of the NDSS show that data quality is exceptional; iii) Multiple research systems’ data and research findings can be checked and cross-checked for consistency and reliability; iv) Most importantly, Navrongo research permits causal inference about what works and what fails. Longitudinal research, in conjunction with experimental designs, produces results that are not subject to challenge or alternative explanations.

Conclusion

The Navrongo Experiment has demonstrated, in an inauspicious social and economic environment, practical means for implementing Ghana’s longstanding goal to develop community-based primary health care that works. Early results have challenged conventional wisdom about what works and what fails. The Navrongo research systems show that long-term observation is required and that overly simplistic investigation based on single-round surveys alone may lead to spurious conclusions and inappropriate policy advice since survey responses may not permit crosschecking and careful analysis. If the experiment succeeds—and impact measured so far suggests that it will—substantive project hypotheses will be supported; no Sahelian setting is fundamentally inhospitable to the introduction and success of community-based PHC care and family planning. Establishing this insight requires the rigorous research systems that the NHRC has so comprehensively developed.

Frequently Asked Questions

Cost	Q	The NHRC has equipment, facilities, and resources for research that most districts lack. How can a district possibly replicate the CHFP without access to these special resources?
	A	The NHRC always separates research operations from service delivery operations. All CHFP services are undertaken by the DHMT and use resources that are deliberately constrained to replicable levels.
Contamination by research activities	Q	With so many research activities going on in Kassena-Nankana District, are the research activities changing communities in ways that bias results?
	A	The NDSS involves about 10 minutes of interviewing of every compound head in the district every 90 days. NDSS interviewing is not a significant intrusion into people's lives. The Panel Survey is conducted once a year in about 1,600 compounds. There is no evidence that panel responses differ from responses in households where there is less interviewing.
Societal gains from research	Q	Research generates findings that scientists publish and disseminate. But, do the people of Kassena-Nankana District really benefit from research? Do they even know what the research is for and what has been learned?
	A	The CHFP consults with communities about research activities and explains the goals and purposes of studies before they are conducted. Dissemination of results includes community durbars on findings. Ways in which communities have benefited from the services associated with experimental studies are reviewed and discussed at the end of studies. In the case of the CHFP, which is a multi-year effort, this process of dialogue is continuous.
Policy benefits from research	Q	Research costs money. How does the MOH benefit from this programme? Why not have a training and demonstration programme in Navrongo rather than a complicated research initiative?
	A	From the onset of the CHFP, activities have been guided by unanswered policy questions. Results are designed to produce evidence for decisionmaking. Evidence-based policy development saves resources by creating programmes that are efficient and effective. The national programme entitled the “Community-based Health Planning and Services” (CHPS) initiative is a national effort to utilize results from The Navrongo Experiment for large-scale health programme reform.