Awoonor-Williams John Koku, Phillips James F
Policy Planning Monitoring and Evaluation Division, Ghana Health Service Accra Ghana.
Heilbrunn Department of Population and Family Health, Mailman School of Public Health Columbia University New York New York USA.
Learn Health Syst. 2021 Jun 22;6(1):e10282. doi: 10.1002/lrh2.10282. eCollection 2022 Jan.
Achieving effective community-based primary health care requires evidence for guiding strategic decisions that must be made. However, research processes often limit data collection to particular organizational levels or disseminate results to specific audiences. Decision-making that emerges can fail to account for the contrasting perspectives and needs of managers at each organizational level. The Ghana Health Service (GHS) addressed this problem with a multilevel and sequential research and action approach that has provided two decades of implementation learning for guiding community-based primary health care development.
The GHS implementation research initiatives progressed from (i) a participatory pilot investigation to (ii) an experimental trial of strategies that emerged to (iii) replication research for testing scale-up, culminating in (iv) evidence-based scale-up of a national community-based primary health care program. A reform process subsequently repeated this sequence in a manner that involved stakeholders at the community, sub-district, district, and regional levels of the system. The conduct, interpretation, and dissemination of results that emerged comprised a strategy for achieving systems learning by conducting investigations in phases in conjunction with bottom-up knowledge capture, lateral exchanges for fostering peer learning at each system level, and top-down processes for communicating results as policy. Continuous accumulation of qualitative data on stakeholder reactions to operations at each organizational level was conducted in conjunction with quantitative monitoring of field operations.
Implementation policies were enhanced by results associated with each phase. A quasi-experiment for testing the reform process showed that scale-up of community-based primary health care was accelerated, leading to improvements in childhood survival and reduced fertility.
Challenges to system learning were overcome despite severe resource constraints. The integration of knowledge generation with ongoing management processes institutionalized learning for achieving evidence-driven program action.
要实现有效的基于社区的初级卫生保健，需要有证据来指导必须做出的战略决策。然而，研究过程往往将数据收集限制在特定的组织层面，或将结果传播给特定的受众。由此产生的决策可能无法考虑到每个组织层面管理者的不同观点和需求。加纳卫生服务局（GHS）通过一种多层次、循序渐进的研究与行动方法解决了这一问题，该方法为指导基于社区的初级卫生保健发展提供了二十年的实施经验。
GHS的实施研究计划从（i）参与式试点调查发展到（ii）对出现的策略进行实验性试验，再到（iii）用于测试扩大规模的复制研究，最终以（iv）基于证据的全国性基于社区的初级卫生保健计划扩大规模告终。随后的一个改革过程以一种让系统的社区、分区、地区和区域层面的利益相关者参与的方式重复了这一顺序。对所产生结果的开展、解释和传播构成了一种通过分阶段进行调查、结合自下而上的知识获取、在每个系统层面促进同行学习进行横向交流以及将结果作为政策进行自上而下沟通来实现系统学习的策略。在对实地行动进行定量监测的同时，持续积累关于利益相关者对每个组织层面行动反应的定性数据。
与每个阶段相关的结果加强了实施政策。一项用于测试改革过程的准实验表明，基于社区的初级卫生保健的扩大规模得以加速，从而提高了儿童存活率并降低了生育率。
尽管资源严重受限，但仍克服了系统学习面临的挑战。将知识生成与持续管理过程相结合，使学习制度化，以实现基于证据的项目行动。
