Developing organizational learning for scaling-up community-based primary health care in Ghana

Introduction: 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 multi-level and sequential research and action approach that has provided two decades of implementation learning for guiding community-based primary health care development. Methods: 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. Results: 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. Conclusion: 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.