Lessons Learnt through the Implementation of the USAID Strengthening the Care Continuum Project in Rural Communities in the Western Region of Ghana
The West Africa AIDS Foundation (WAAF) is a non-governmental organization that was started in 1999 aimed at helping deliver quality health care, specifically to people living with HIV and AIDS in Ghana. Since the start of the foundation, WAAF along with its onsite medical clinic, IHCC, has been able to provide education, screening, testing, treatment, and outreach programs to the marginalized society in the areas throughout Ghana they serve.
WAAF has multiple on-going projects that target a wide range of key populations from people living with HIV to healthy mothers to corruption in Ghana, and many more. Their USAID Strengthening the Care Continuum Project is funded by the USAID and the John Snow Research and Training Institute (JSI). This project started implementation in the Western Region in October 2019. The goal is to collaborate with the Government of Ghana to provide high quality and comprehensive HIV services for key populations of people living with HIV (PLHIV). The key population that WAAF targets in this project are men who have sex with men (MSM). The following are the objectives of the project:
- Increase the availability and access to comprehensive prevention care and treatment services, including reliable coverage across the continuum of care for MSM and PLHIV
- Enhance and sustain the demand for comprehensive prevention, care, and treatment services among key populations
- Strengthen the linkage and retention in care of key populations who test positive for HIV
- Strengthen the systems for planning, monitoring, and evaluating and ensuring the quality of programs
The National HIV & AIDS Strategic Plan 2016-2020 found that MSM are at a higher risk of contracting and transmitting STIs and HIV. Stigma and discrimination against MSM in Ghana is also a problem and makes it difficult for key populations to seek preventative care, testing, or treatment. Although the national HIV prevalence in Ghana is believed to be 1.7% (UNAIDS, 2018), the prevalence among MSM is estimated to be as high as 17.5% (The Global Fund, 2019).
Since the start of the program, WAAF has made progress in reaching key populations. From starting the program in October 2019 through May 2020, WAAF has reached 499 individuals, testing 407 (81%) of them. Of these individuals, 41 (10%) were positive and 35 (85%) were initiated into treatment.
Although WAAF has been making progress, there have been challenges in implementing the project in the Western Region of Ghana. These challenges have interfered with the project reaching their goals and objectives.
To detail the key challenges during implementation of the Care Continuum Project that tend to sit in the way of the project reaching target populations and therefore achieving the desired set of results.
Purpose of the Evaluation
The purpose of this evaluation is to outline the main challenges program staff are facing during the implementation of key population (KP) focused projects in rural settings, such as the Care Continuum Project in the Western Region of Ghana that are limiting them from reaching their target goals and objectives. This evaluation will help the project team, West Africa AIDS Foundation, and funders develop improved methods and create more attainable goals. The main consideration of this evaluation is the difference between projects implemented in rural areas versus urban areas. To identify these challenges, an evaluation was given to key members of the Care Continuum Project team including the program coordinator, field officers, and volunteers. The evaluation consisted of multiple choice and open ended questions to address what challenges are being faces, the priority of challenges, and how these challenges are impacting their ability to complete their assignments.
Significance of the Problem
Although the population of Ghana as has an HIV prevalence of 1.7% (NACP, 2017), it is estimated that the prevalence among MSM within Ghana is around 18% (The Global Fund, 2019). According to the 2014 Ghana Demographic and Health Survey, HIV prevalence in Ghana is highest in the Eastern Region at 2.8%, the Western Region at 2.7%, and Greater Accra Region at 2.5% (The Global Fund, 2019). They have also found that prevalence continues to be higher in urban areas at 2.5% rather than rural areas at 1.9% (The Global Fund, 2019). In 2015, there was a regional prevalence of HIV among MSM in Accra reaching 34% (The Global Fund, 2019). The prevalence rate among MSM in the Ashanti Region, which holds Kumasi, Ghana’s second biggest city, is 14% (Ogunbajo et al., 2018). The high prevalence rate in Accra and Kumasi indicates that a higher number of MSM are living in larger cities.
Adults over the age of 15 living with HIV in Ghana is estimated to be 310,000, with 100,000 of them being men (UNAIDS, 2018). The MSM population of Ghana is estimated to be 54,800 and 18% of that population is HIV positive (UNAIDS, 2018). Of that 18%, only 3.7% are on antiretroviral therapy (UNAIDS, 2018). Reaching the remaining individuals within that population has been proven difficult over the years. MSM in Ghana experience high levels of stigma, social isolation, and discrimination (Ogunbajo et al., 2018). In Ghana, same-sex sexual practices can lead to imprisonment for a term of at least five years (Ogunbajo et al., 2018). Another obstacle for MSM seeking HIV care is a hostile and unaccepting environment for HIV-infected MSM (Ogunbajo et al., 2018). These barriers can cause MSM to leave rural areas to live in more populated cities for multiple reasons. Accra has the highest population of MSM in Ghana with an estimated number of 20,822 (Ogunbajo et al., 2018). One reason being they will have a better chance of finding other MSM and have a safe space to feel comfortable in. It also allows them more opportunity to find employment and seek medical care in areas where people do not know them. Larger cities have multiple hospitals and clinics where MSM are able to choose where they receive treatment from as opposed to rural communities that may only have one health center.
Because of these barriers, MSM in rural areas of Ghana are particularly hard to reach. This may also negatively influence health-seeking behaviors and health outcomes for HIV infected MSM (Ogunbajo et al., 2018). Based on a study done in 2015, the number one reason seen as a barrier to HIV care was being seen in HIV related health care settings (Ogunbajo et al., 2018). In rural communities this is even more so of a barrier due to the smaller population size and likelihood of seeing someone you know in your community at or around medical clinics. Participants also put off seeking treatment because they were afraid people would start rumors around their community to their friends and family (Ogunbajo et al., 2018).
The evaluation consisted of a questionnaire distributed to key, mostly front line staff of the project. An example can be seen in Appendix A. The questionnaire asked questions to identify the challenges being faced, the level of difficulty for each challenge, a description of these challenges, and how the challenges impacted the participants’ ability to complete their work. The evaluation consisted of both multiple choice questions and open-ended questions to allow participants to fully explain any challenges they are experiencing. A total of 10 participants completed the evaluation using Google Forms and this was done anonymously to protect their answers. These participants have different roles within the CCP including field officers, monitoring and evaluation officers, case managers, and peer educators. Limitations of this evaluation include the small size and some participants not expanding on open-ended questions because of the online nature of the evaluation.
There were nine challenges indicated by the participants of the evaluation. 70% of the individuals reported that due to the low number of MSM in the area, reaching set target numbers is a challenge. 30% of participants indicated that they are unable to reach set target populations due to challenges in identifying MSM in the area. 80% of participants indicated that target populations do not want to seek care from clinics and/or organizations that are known to provide HIV care and are afraid or unwilling to seek care. 90% of participants also reported that the high level of stigma towards target populations is a challenge. 70% of individuals indicated difficulty finding consistent volunteers in the Western Region and 40% reported a lack of standardization in volunteers in the Western Region. 50% of participants indicated the challenge of extremely high targets to reach for the project and another 80% reported low budget allocation as a challenge. 40% of participants reported other challenges that were explained in their open-ended section of the evaluation.
The next section of the evaluation was to determine the level of difficulty of each challenge. Each challenge was asked to be indicated as very challenging, somewhat challenging, slightly challenging, or not challenging, which can be seen in Figure 1. The challenge that showed the most difficulty with seven participants indicating “very challenging” was a high level of stigma towards target populations. Two participants indicated this challenge as somewhat challenging. The next most difficult challenge was the inability to reach target populations due to low number of MSM in the area with six participants indicating a very challenging difficulty, and three indicating somewhat challenging. In addition to this challenge, low budget allocation was seen as another difficult challenge with six participants indicating it to be very challenging, one somewhat challenging, and two slightly challenging. The following challenges were seen as moderate difficulty level based on responses: unable to reach target populations due to inability to identify because of low numbers of MSM in area, target populations do not want to seek care from clinics and/or organizations that are known or provide HIV are, target populations are afraid or unwilling to seek care, difficulty finding consistent volunteers, lack of standardization in volunteers, and other challenges.
In the third and fourth section of the evaluation, the participants were asked to describe all the challenges they have faced while implementing the Care Continuum Project in the Western Region of Ghana with the West Africa AIDS Foundation and how these challenges impacted their ability to implement the program. Seven of the participants discussed the challenge of stigma within the target population the challenges that brings. These challenges included target populations not wanting to discuss their problems or seek care, target populations denying services, and target populations feeling as if they don’t have a safe space within the area. Another challenge that was mentioned related to stigma was some MSM not wanting to disclose their partner for index testing as they believe this would be a betrayal to their partner. Because of the stigma associated with MSM, participants found that target populations are more likely to hide their identities in these smaller towns compared to larger cities, which makes it difficult to find and identify them for services.
Another main challenge reported was allocation and delay of funds. These challenges were reported by four participants and indicated that delay of funds also delayed activities planned for the CCP participants. This causes some CCP participants to drop out of the program. This has also caused challenges with the staff because some activities then need to be reorganized once they are delayed, which in turn causes their other work to be delayed. One individual reported that funds for refreshments before or after activities would help encourage peers in the area to attend activities. Two participants reported challenges regarding lack of volunteers. One individual indicated that in Ellembelle, there was one point when the program only had two volunteers doing the work of four volunteers. Another challenge three participants indicated was the high target numbers given for the project compared to the actual number of MSM in the area, which has made it difficult to reach project goals and objectives. Lastly, one participant reported that the door-to-door approach they are using for the CCP is very challenging and recommended changing the way they are reaching target populations for testing. This individual would like to see a change in approach every few weeks as a way to diversify their reach.
Recommendations & Conclusion
Based on the findings from the evaluation there are four main challenges faced while implementing the Care Continuum Project in the Western Region. These challenges are stigma, funds, volunteers, and target numbers. From these findings, recommendations focus on these four challenges.
Stigma among MSM and HIV/AIDS are still very prevalent in Ghana which is keeping target populations from receiving services they need to remain healthy. Because of this, it shows that education is one of the most important aspects to breaking this barrier. A key aspect of being successful in the CCP is increasing education among the general population and health care workers in the Western Region on HIV/AIDS and MSM. Decreasing this stigma would allow more key populations to seek preventative services and treatment when needed without feeling targeted or unsafe.
Another challenge being faced is target populations afraid to seek care because of being seen or not having a safe space. The CCP needs to create more discreet and private program locations that will allow participants to receive services and come to programs without the fear of being seen by people in the community. One way this can be done is by creating confidential partnerships with local businesses and utilizing their spaces when allowed. This can also be done by eliminating WAAF logos during programs and during services.
A common challenge reported was delay of funds or lack of funds, which delayed and interfered with CCP staff from completing their tasks. The delay in funds caused programs to be canceled or rescheduled which caused participants to drop out and having to re-plan events. To alleviate this challenge, funds need to be more consistent. Another challenge reported was a lack of funds. Increasing funds can improve the quality of the programs and provide a small incentive to participants for completing the program such as money or refreshments during the events.
The next challenge was the inconsistency and low commitment levels of volunteers. One participant from the evaluation reported at one point of the program there were only two volunteers doing the work of four volunteers. One way to increase the number of volunteers and maintain them on the project is to standardize volunteers allowances across all CSOs engaged on CCP and offer incentives such as monthly communication allowance, provide weekly transportation allowance to cater for all extra travel expenses incurred during field activities. Volunteers should also be afforded the opportunity to participate in national and international conferences and exchange learning programs to boost their confidence and also feel relevant to the project. This will motivate community members and encourage them to take part of the project and give off their best with a greater expectation of life time opportunities.
Lastly, a common challenge reported was high target numbers to reach compared to the low number of MSM in the area, MSM not wanting to receive care, and MSM hiding their identities in smaller towns. Combined with the other recommendations listed above, lowering the target numbers will help alleviate this challenge. Targets should be set using baseline data from specific areas the project will be implemented. Once the new target number is reached, slow increases can continue to be made overtime. This will allow for more target populations to be reached without setting unrealistic goals and objectives at the start of the program. Another challenge related to the target numbers reported was the way in which key populations were being reached.
Due to the small sample size of the evaluation, some of the results were difficult to analyze. Although, many challenges were reported by a majority of the participants showing that stigma, lack of funds, volunteers, and high target numbers are important challenges being faced while implementing the Care Continuum Project in the Western Region of Ghana by the West Africa AIDS Foundation. Therefore, in future evaluations questionnaires should focus on these challenges while asking participants the best ways to combat them. Increasing the sample size would help show the severity of these challenges in the future. It is clear that decreasing stigma, increasing and keeping funds consistent, finding more volunteers, and adjusting the target numbers would help improve productivity for the program.
- The Global Fund. (2019). Baseline assessment – Ghana: scaling up programs to remove
- human rights related barriers to HIV services. https://www.theglobalfund.org/media/8720/crg_humanrightsbaselineassessmentghana_report_en.pdf?u=637166000610000000
- Ogunbajo, A., Kershaw, T., Kushwaha, S., Boakye, F., Wallace-Atiapah, N. D., Nelson, L. E. (2018). Barriers, motivators, and facilitators to engagement in HIV care among HIV-infected Ghanaian men who have sex with men (MSM). AIDS and Behavior, 22(3), 829-839. doi:10.1007/s10461-017-1806-6
- UNAIDS. (2018). Ghana. https://www.unaids.org/en/regionscountries/countries/ghana
- U.S. Department of Health and Human Services, Centers for Disease Control and Prevention
- (2011). Introduction to program evaluation for public health programs: A self-study guide. https://www.cdc.gov/eval/guide/cdcevalmanual.pdf
Directions: The purpose of this evaluation is to outline the challenges seen in implementing the Care Continuum Project in the Western Region of Ghana with the West Africa AIDS Foundation. The completion of this evaluation is voluntary and anonymous. You can stop the evaluation at anytime you would like if you feel the need to. The responses from this evaluation will be used by the West Africa AIDS Foundation and funders for the Care Continuum Project to make positive adjustments to the program regarding challenges being faced. Please answer the following questions to the best of your ability and be as honest as possible. We thank you for your participation.
- When implementing the Care Continuum Project (CCP) in the Western Region of Ghana, please select any and all challenges you have faced:
- Unable to reach target populations due to low number of MSM in area
- Unable to reach target populations due to inability to identify MSM in area
- Target populations (MSM) do not want to seek care from clinics/organizations that are known to provide HIV care
- Target populations (MSM) are afraid/unwilling to seek care
- High level of stigma towards target populations
- Difficulty finding consistent volunteers in the Western Region
- Lack of standardization in volunteers in the Western Region
- Extremely high targets to reach for project
- Low budget allocation
- Other Challenges (Please indicate all other challenges faced in Table 1and Question 3)
- Table 1: When implementing the CCP in the Western Region of Ghana, please indicate with an Xfor each challenge the level of difficulty you have experienced: very challenging, somewhat challenging, slightly challenging, or not challenging.
- When implementing the Care Continuum Project (CCP) in the Western Region of Ghana, please select any and all challenges you have faced:
|Very Challenging||Somewhat Challenging||Slightly Challenging||Not Challenging|
|a. Unable to reach target populations due to low number of MSM in area|
|b. Unable to reach target populations due to inability to identify MSM in area|
|c. Target populations (MSM) do not want to seek care from clinics/organizations that are known to provide HIV care|
|d. Target populations (MSM) are afraid/unwilling to seek care|
|e. High level of stigma towards target populations|
|f. Difficulty finding consistent volunteers in the Western Region|
|g. Lack of standardization in volunteers in the Western Region|
|h. Extremely high targets to reach for study|
|i. Low budget allocation|
|j. Other – Please indicate challenges|
3. Please write a description of all the challenges you have faced while implementing the Care Continuum Project in the Western Region of Ghana with the West Africa AIDS Foundation and any challenges that were not listed above. Be as specific as possible and include the level of difficult for challenges using very challenging, somewhat challenging, slightly challenging, or not challenging. Please include any other comments or concerns you would like to address regarding the CCP in the Western Region.
- Please explain how the challenges you indicated above impact your ability to complete the work you are assigned to do with the West Africa AIDS Foundation and what these challenges have resulted in. Be as specific as possible.