STREET-LEVEL BUREAUCRATS IN COMMUNITY-BASED HEALTH INITIATIVES: A CASE STUDY OF AGONA WEST

Öz

This study examines how street-level bureaucrats (SLBs) implement community-based health initiatives (CBHIs) in Ghana's Agona West Municipality through the Community-based Health Planning and Services (CHPS) program. The researcher employed a mixed-methods approach to investigate SLBs' discretionary practices to manage resource constraints and conflicting demands, implementation challenges, and coping strategies. Data were collected from 60 SLBs through surveys, 20 SLBs through in-depth interviews, and 32 community members through focus group discussions. Findings reveal that SLBs perform diverse roles, including service provision, health education, and surveillance, frequently expanding these roles based on community needs. They exercise significant discretion through service prioritization, protocol adaptation, and resource mobilization, particularly in resource-constrained rural settings. Implementation challenges include resource limitations, administrative burden, and policy-practice gaps. SLBs employ coping strategies such as task prioritization, creative resource mobilization, and community engagement. This study contributes to street-level bureaucracy theory by demonstrating recursive relationships between challenges, discretion, and coping strategies in African healthcare contexts. The researcher recommends realistic policy design, reduced administrative burden, supportive supervision, and systematic learning from SLBs' innovations to strengthen community-based health systems.

Anahtar Kelimeler

• Street-level bureaucrats
• community health
• policy implementation
• coping strategies
• health systems.

TOPLUM TEMELLİ SAĞLIK GİRİŞİMLERİNDE SOKAK DÜZEYİNDEKİ BÜROKRATLAR: AGONA WEST'TE BİR VAKA ÇALIŞMASI

Öz

Bu çalışma, Toplum Temelli Sağlık Planlaması ve Hizmetleri (CHPS) programı aracılığıyla Gana'nın Agona West Belediyesi’nde sokak düzeyindeki bürokratların (SDB'ler) toplum temelli sağlık girişimlerini (CBHI'ler) nasıl uyguladıklarını incelemektedir. SDB'lerin kaynak kısıtlamalarını ve çelişen talepleri, uygulama zorluklarını ve başa çıkma stratejilerini yönetmeye yönelik isteğe bağlı uygulamalarını araştırmak için karma yöntem yaklaşımı kullanılmıştır. Anketler aracılığıyla 60 SDB'den, derinlemesine görüşmeler aracılığıyla 20 SDB'den ve odak grup tartışmaları aracılığıyla 32 topluluk üyesinden veri toplanmıştır. Bulgular, SDB'lerin hizmet sunumu, sağlık eğitimi ve gözetim dahil olmak üzere çeşitli roller üstlendiğini ve bu rolleri sıklıkla toplumun ihtiyaçlarına göre genişlettiğini ortaya koymaktadır. Özellikle kaynakların kısıtlı olduğu kırsal ortamlarda hizmet önceliklendirmesi, protokol uyarlaması ve kaynak seferberliği yoluyla önemli ölçüde takdir yetkisi kullanmaktadırlar. Uygulama zorlukları arasında kaynak sınırlamaları, idari yük ve politika-uygulama boşlukları yer almaktadır. SDB'ler görev önceliklendirme, yaratıcı kaynak seferberliği ve toplum katılımı gibi başa çıkma stratejileri kullanmaktadır. Bu çalışma; Afrika sağlık sistemi bağlamlarında zorluklar, takdir yetkisi ve başa çıkma stratejileri arasındaki özyinelemeli ilişkileri göstererek sokak düzeyinde bürokrasi teorisine katkıda bulunmaktadır. Toplum temelli sağlık sistemlerini güçlendirmek için gerçekçi politika tasarımı, azaltılmış idari yük, destekleyici denetim ve SDB'lerin yeniliklerinden sistematik öğrenme önerilmektedir.

Anahtar Kelimeler

• Sokak düzeyinde bürokratlar
• toplum sağlığı
• politika uygulaması
• başa çıkma stratejileri
• sağlık sistemleri.

Kaynakça

1. Abekah-Nkrumah, G., & Nkrumah, J. (2021). Perceived work environment and patient-centered behavior: A study of selected district hospitals in the central region of Ghana. PLoS One, 16(1), e0244726. https://doi.org/10.1371/journal.pone.0244726
2. Abekah-Nkrumah, G., Issiaka, S., Virgil, L., & Ermel, J. (2018). A review of the process of knowledge transfer and use of evidence in reproductive and child health in Ghana. Health Research policy and systems, 16, 1-29. https://doi.org/10.1186/s12961-018-0350-9
3. Aberese-Ako, M., Van Dijk, H., Gerrits, T., Arhinful, D. K., & Agyepong, I. A. (2014). 'Your health our concern, our health whose concern?'Perceptions of injustice in organizational relationships and processes and frontline health worker motivation in Ghana. Health policy and planning, 29(suppl_2), ii15-ii28. https://doi.org/10.1093/heapol/czu068
4. Adongo, P. B., Phillips, J. F., Aikins, M., Arhin, D. A., Schmitt, M., Nwameme, A. U., ... & Binka, F. N. (2014). Does the design and implementation of proven innovations for delivering basic primary health care services in rural communities fit the urban setting: the case of Ghana's Community-based Health Planning and Services (CHPS). Health research policy and systems, 12, 1-10. https://doi.org/10.1186/1478-4505-12-16
5. Adongo, P. B., Tapsoba, P., Phillips, J. F., Tabong, P. T. N., Stone, A., Kuffour, E., ... & Akweongo, P. (2014). "If you do vasectomy and come back here weak, I will divorce you": a qualitative study of community perceptions about vasectomy in Southern Ghana. BMC International Health and Human Rights, 14, 1-8. https://doi.org/10.1186/1472-698X-14-16
6. Adusei, A., Bour, H., Amu, H., & Afriyie, A. (2023). Community-based Health Planning and Services (CHPS) Programme in Ghana: A systematic review. Journal: Frontiers in Public Health, 12, 1337803. https://doi.org/10.3389/fpubh.2024.1337803
7. Agyepong, I. A., Sewankambo, N., Binagwaho, A., Coll-Seck, A. M., Corrah, T., Ezeh, A., ... & Piot, P. (2017). The path to longer and healthier lives for all Africans by 2030: the Lancet Commission on the future of health in sub-Saharan Africa. The Lancet, 390(10114), 2803-2859. https://doi.org/10.1016/S0140-6736(17)31509-X
8. Alhassan, R. K., Nketiah-Amponsah, E., & Arhinful, D. K. (2016). A review of the National Health Insurance Scheme in Ghana: what are the sustainability threats and prospects?. PloS one, 11(11), e0165151. https://doi.org/10.1371/journal.pone.0165151

9. Amogre Ayanore, M., Pavlova, M., Kugbey, N., Fusheini, A., Tetteh, J., Ayanore, A. A., Akazili, J., Adongo, P. B., & Groot, W. (2019). Health insurance coverage, type of payment for health insurance, and reasons for not being insured under the National Health Insurance Scheme in Ghana. SpringerMA Ayanore, M Pavlova, N Kugbey, A Fusheini, J Tetteh, AA Ayanore, J Akazili, PB AdongoHealth Economics Review, 2019•Springer, 9(1). https://doi.org/10.1186/s13561-019-0255-5
10. Andersen, S. C., & Nielsen, H. S. (2020). Learning from performance information. Journal of Public Administration Research and Theory, 30(3), 415-431. https://doi.org/10.1093/jopart/muz036
11. Appiagyei, P. (2017). Access to healthcare through nhis; factors limiting enrolment of the poor unto the national health insurance scheme in ghana. Vrije Universiteit.
12. Arthur, B. R. I. G. H. T. (2019). A toponomastic study of suburb names from some Agona towns in the Central region.
13. Arthur, G. B. (2016). Rural-urban migration and household livelihoods in the Agona West Municipality, Ghana (Doctoral dissertation, University of Cape Coast).
14. Assan, A., Takian, A., Aikins, M., & Akbarisari, A. (2018). Universal health coverage necessitates a system approach: an analysis of Community-based Health Planning and Services (CHPS) initiative in Ghana. Globalization and health, 14, 1-10. https://doi.org/10.1186/s12992-018-0426-x
15. Assan, A., Takian, A., Aikins, M., & Akbarisari, A. (2019). Challenges to achieving universal health coverage through community-based health planning and services delivery approach: a qualitative study in Ghana. BMJ open, 9(2), e024845. https://doi.org/10.1136/bmjopen-2018-024845
16. Awoonor Williams, J. K., Phillips, J. F., & Bawah, A. A. (2019). Scaling down to scale-up: a strategy for accelerating community-based health service coverage in Ghana. Journal of Global Health Science, 1(1). https://doi.org/10.35500/jghs.2019.1.e9
17. Awoonor‐Williams, J. K., & Phillips, J. F. (2022). Developing organizational learning for scaling‐up community‐based primary health care in Ghana. Learning Health Systems, 6(1), e10282. https://doi.org/10.1002/lrh2.10282
18. Awoonor-Williams, J. K., Phillips, J. F., Aboba, M., Vadrevu, L., Azasi, E., Tiah, J. A. Y., ... & Kachur, S. P. (2022). Supporting the utilization of community-based primary health care implementation research in Ghana. Health Policy and Planning, 37(3), 420-427. https://doi.org/10.1093/heapol/czab156
19. Awoonor-Williams, J. K., Phillips, J. F., Bawah, A. A., Awoonor-Williams, J. K., Phillips, J. F., & Bawah, A. A. (2017). The application of embedded implementation science to developing community-based primary health care in Ghana. Int J Popul Dev Reprod Heal, 1(1), 66-81.
20. Ayanore, M. A., Amuna, N., Aviisah, M., Awolu, A., Kipo-Sunyehzi, D. D., Mogre, V., ... & Gyapong, M. (2019). Towards resilient health systems in sub-Saharan Africa: a systematic review of the English language literature on health workforce, surveillance, and health governance issues for health systems strengthening. Annals of global health, 85(1), 113. https://doi.org/10.5334/aogh.2514
21. Baatiema, L., Sumah, A. M., Tang, P. N., & Ganle, J. K. (2016). Community health workers in Ghana: the need for greater policy attention. BMJ global health, 1(4), e000141. https://doi.org/10.1136/bmjgh-2016-000141
22. Baatiema, L., Aikins, A. D. G., Koram, K. K., Kunfah, S. M. P., Allen, L. N., Abimbola, S., & Kruk, M. (2024). Frontline health workers' experiences of providing care for people living with non-communicable diseases during the COVID-19 pandemic in Ghana: a qualitative study. BMJ open, 14(5), e078957.
23. Babbie Ed D, S. (2021). Higher Education Leadership Perspectives: Autism Education Certification and Teacher Shortages in Upstate New York.
24. Bassoumah, B., Adam, A. M., & Adokiya, M. N. (2021). Challenges to the utilization of Community-based Health Planning and Services: the views of stakeholders in Yendi Municipality, Ghana. BMC Health Services Research, 21, 1-9. https://doi.org/10.1186/s12913-021-07249-8
25. Bouckaert, G. (2023). The neo-Weberian state: From ideal type model to reality?. Max Weber Studies, 23(1), 13-59. https://doi.org/10.1353/max.2023.0002
26. Bouckaert, G., Peters, B. G., & Verhoest, K. (2022). Policy design for policy coordination. In Research handbook of policy design (pp. 351-370). Edward Elgar Publishing. https://doi.org/10.4337/9781839106606.00032 Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative research in psychology, 3(2), 77-101. https://doi.org/10.1191/1478088706qp063oa
27. Brodkin, E. Z. (2012). Reflections on street‐level bureaucracy: past, present, and future. https://doi.org/10.1111/j.1540-6210.2012.02657.x
28. Carter, N. (2014). The use of triangulation in qualitative research. Number 5/September 2014, 41(5), 545-547. https://doi.org/10.1188/14.ONF.545-547
29. Chang, A., & Brewer, G. A. (2023). Street-level bureaucracy in public administration: A systematic literature review. Public management review, 25(11), 2191-2211. https://doi.org/10.1080/14719037.2022.2065517
30. Cheng, T., Mauno, S., Industrial, C. L.-E. and, & 2014, undefined. (2014). The buffering effect of coping strategies in the relationship between job insecurity and employee well-being. Journals.Sagepub.Com, 35(1), 71-94. https://doi.org/10.1177/0143831X12463170
31. Creswell, J. W., & Clark, V. L. P. (2017). Designing and conducting mixed methods research. Sage publications.
32. Creswell, J. W., & Poth, C. N. (2016). Qualitative inquiry and research design: Choosing among five approaches. Sage publications.
33. Debpuur, C., Phillips, J. F., Jackson, E. F., Nazzar, A., Ngom, P., & Binka, F. N. (2002). The impact of the Navrongo Project on contraceptive knowledge and use, reproductive preferences, and fertility. Studies in family planning, 33(2), 141-164.
34. Dadzie, D. D. (2017). Assessment of the effects of microfinance on rural communities in Agona district in the central region of Ghana (Doctoral dissertation, University of Cape Coast).
35. Elsey, H., Abboah-Offei, M., Vidyasagaran, A. L., Anaseba, D., Wallace, L., Nwameme, A., ... & Agyepong, I. (2023). Implementation of the Community-based Health Planning and Services (CHPS) in rural and urban Ghana: a history and systematic review of what works, for whom and why. Frontiers in public health, 11, 1105495. https://doi.org/10.3389/fpubh.2023.1105495 Erasmus, E. (2014). The use of street-level bureaucracy theory in health policy analysis in low-and middle-income countries: a meta-ethnographic synthesis. Health policy and planning, 29(suppl_3), iii70-iii78. https://doi.org/10.1093/heapol/czu112
36. Fagotto, E., Research, A. F.-J. of U. and R., & 2006, undefined. (2006). Empowered participation in urban governance: the Minneapolis neighborhood revitalization program. Wiley Online Library, 30(3), 638-655. https://doi.org/10.1111/j.1468-2427.2006.00685.x
37. Fiveable (2025). https://fiveable.me/key-terms/introduction-public-health/community-based-healthcare - Accessed Date: 21/01/2025).
38. Frimpong, J. A., Helleringer, S., Awoonor‐Williams, J. K., Yeji, F., & Phillips, J. F. (2011). Does supervision improve health worker productivity? Evidence from the Upper East Region of Ghana. Tropical Medicine & International Health, 16(10), 1225-1233. https://doi.org/10.1111/j.1365-3156.2011.02824.x
39. Fung, A. (2009). Empowered participation: Reinventing urban democracy. https://www.torrossa.com/gs/resourceProxy?an=5573476&publisher=FZO137 https://doi.org/10.1515/9781400835638
40. Fung, A. (2001). Accountable autonomy: Toward empowered deliberation in Chicago schools and policing. Politics & Society, 29(1), 73-103. https://doi.org/10.1177/0032329201029001004
41. Ganle, J. K., Otupiri, E., Obeng, B., Edusie, A. K., Ankomah, A., & Adanu, R. (2016). Challenges women with disability face in accessing and using maternal healthcare services in Ghana: a qualitative study. PloS one, 11(6), e0158361. https://doi.org/10.1371/journal.pone.0158361
42. Gbagbo, F. Y., & Nkrumah, J. (2021). Self-medication among pregnant women in two municipalities in the Central Region of Ghana. Health Care for Women International, 42(4-6), 547-562. https://doi.org/10.1080/07399332.2020.1716235
43. Ghana. Ministry of Health. (2020). National health policy: ensuring healthy lives for all. Ministry of Health, Republic of Ghana.
44. Ghana. Statistical Service. (2014). Ghana Living Standards Survey Round 6 (GLSS 6).: Poverty profile in Ghana (2005-2013). Ghana Statistical Service.
45. Gilson, L. L. (2015). Michael Lipsky, street-level bureaucracy: Dilemmas of the individual in public service. https://doi.org/10.1093/oxfordhb/9780199646135.013.19
46. Gilson, L., Schneider, H., & Orgill, M. (2014). Practice and power: a review and interpretive synthesis focused on the exercise of discretionary power in policy implementation by front-line providers and managers. Health policy and planning, 29(suppl_3), iii51-iii69. https://doi.org/10.1093/heapol/czu098
47. Guest, G., Bunce, A., & Johnson, L. (2006). How many interviews are enough? An experiment with data saturation and variability. Field methods, 18(1), 59-82. https://doi.org/10.1177/1525822X05279903
48. Gyasi, R. M., Hajek, A., Asante, F., Accam, B. T., Osei‐Tutu, S., Rahmati, M., ... & Phillips, D. R. (2023). Ageing happily in Ghana: How does social inclusion contribute?. Psychogeriatrics, 23(5), 821-830. https://doi.org/10.1111/psyg.13004
49. Hollis, L. P. (2017). Qualitative phenomenological study: Considerations in engaging international students. Sage Publications Limited. https://doi.org/10.4135/9781526401168
50. Hupe, P., & Hill, M. (2007). Street‐Level bureaucracy and public accountability. Public administration, 85(2), 279-299. https://doi.org/10.1111/j.1467-9299.2007.00650.x
51. Jackson, K., & Bazeley, P. (2019). Qualitative data analysis with NVivo.
52. Jahanbakhsh, M., Esmaeily, A., & Pour, A. B. (2025). Spatio-temporal assessment of land use and land cover dynamics in Urmia lake basin of Iran: A bi-directional approach using optical and radar data on the Google Earth Engine platform. Advances in Space Research, 75(1), 316-330. https://doi.org/10.1016/j.asr.2024.09.039
53. Kok, M., Tolani, M., Mtonga, W., Salamba, T., Mwabungulu, T., Munthali, A., ... & Chinsakaso, B. (2020). Enabling and hindering factors of health surveillance assistants' roles in the provision of contraceptive services in Mangochi, Malawi. Reproductive Health, 17, 1-13.
54. Koduah, A., Baatiema, L., Kretchy, I. A., Agyepong, I. A., Danso-Appiah, A., de Chavez, A. C., ... & Mirzoev, T. (2023). Implementation of medicines pricing policies in Ghana: the interplay of policy content, actors' participation, and context. International journal of health policy and management, 12, 7994. https://doi.org/10.34172/ijhpm.2023.7994
55. Kwamie, A., Dijk, H. V., & Agyepong, I. A. (2014). Advancing the application of systems thinking in health: realist evaluation of the Leadership Development Programme for district manager decision-making in Ghana. Health Research Policy and Systems, 12, 1-12. https://doi.org/10.1186/1478-4505-12-29
56. Kwamie, A., Ha, S., & Ghaffar, A. (2021). Applied systems thinking: unlocking theory, evidence and practice for health policy and systems research. Health Policy and Planning, 36(10), 1715-1717. https://doi.org/10.1093/heapol/czab062
57. Kwamie, A., Van Dijk, H., Ansah, E. K., & Agyepong, I. A. (2016). The path dependence of district manager decision-space in Ghana. Health policy and planning, 31(3), 356-366. https://doi.org/10.1093/heapol/czv069
58. Kweku, M., Amu, H., Awolu, A., Adjuik, M., Ayanore, M. A., Manu, E., ... & Gyapong, J. O. (2020). Community-Based Health Planning and Services Plus programme in Ghana: A qualitative study with stakeholders in two Systems Learning Districts on improving the implementation of primary health care. Plos one, 15(1), e0226808. https://doi.org/10.1371/journal.pone.0226808
59. Lehmann, U., & Gilson, L. (2013). Actor interfaces and practices of power in a community health worker programme: a South African study of unintended policy outcomes. Health policy and planning, 28(4), 358-366. https://doi.org/10.1093/heapol/czs066
60. Lipsky, M. (1980). Street-level bureaucracy: Dilemmas of the individual in public services. Russell Sage Foundation. https://doi.org/10.2307/1288305
61. Lipsky, M. (1984). Bureaucratic Disentitlement in Social Welfare Programs. Social Service Review, 58(1), 3-27. https://doi.org/10.1086/644161
62. Lipsky, M. (2010). Street-level bureaucracy: Dilemmas of the individual in public services (30th anniversary expanded ed.). Russell Sage Foundation.
63. Logie, C. H., Okumu, M., Latif, M., Musoke, D. K., Odong Lukone, S., Mwima, S., & Kyambadde, P. (2021). Exploring resource scarcity and contextual influences on wellbeing among young refugees in Bidi Bidi refugee settlement, Uganda: findings from a qualitative study. Conflict and Health, 15, 1-11. https://doi.org/10.1186/s13031-020-00336-3
64. Malatji, H., Griffiths, F., & Goudge, J. (2023). Community-orientated primary health care: Exploring the interface between community health worker programmes, the health system and communities in South Africa. PLOS global public health, 3(2), e0000881. https://doi.org/10.1371/journal.pgph.0000881
65. Marienfeldt, J. (2024). Does digital government hollow out the essence of street‐level bureaucracy? A systematic literature review of how digital tools' foster curtailment, enablement and continuation of street‐level decision‐making. Social Policy & Administration, 58(5), 831-855. https://doi.org/10.1111/spol.12991
66. Maynard-Moody, S. W., & Musheno, M. C. (2022). Cops, teachers, counselors: Stories from the front lines of public service. University of Michigan Press. https://doi.org/10.3998/mpub.12247078
67. Maynard‐Moody, S., & Musheno, M. (2012). Social equities and inequities in practice: Street‐Level workers as agents and pragmatists. Public administration review, 72(s1), S16-S23. https://doi.org/10.1111/j.1540-6210.2012.02633.x
68. Mills, K. T., Stefanescu, A., & He, J. (2020). The global epidemiology of hypertension. Nature Reviews Nephrology, 16(4), 223-237. https://doi.org/10.1038/s41581-019-0244-2
69. Ministry of Health. (2020). National Health Policy: Ensuring healthy lives for all.
70. Murphy, J. P., Moolla, A., Kgowedi, S., Mongwenyana, C., Mngadi, S., Ngcobo, N., ... & Pascoe, S. (2021). Community health worker models in South Africa: a qualitative study on policy implementation of the 2018/19 revised framework. Health Policy and Planning, 36(4), 384-396. https://doi.org/10.1093/heapol/czaa172 Mwinnyaa, G., Jones, T., Antwi, P., Chan, E., Phillips, J., & Awoonor-Williams, J. K. (2020). Ghana's community health officers and community health volunteers. Health for the People: National Community Health Programs from Afghanistan to Zimbabwe. Edited by Perry H. Baltimore, MD, USA: USAID/Jhpiego, 87-102. Nielsen, J. A., Elmholdt, K., & Noesgaard, M. S. (2022). Shaping the Future Through Anticipation Work. Exploring Digital Transformation in the Public Sector. In Academy of Management Proceedings (Vol. 2022, No. 1, p. 11643). Briarcliff Manor, NY 10510: Academy of Management. https://doi.org/10.5465/AMBPP.2022.273
71. Nii, E., & Okine, A. (2024). An evaluation of community health care service in Ghana: A case of the Community-Based Health and Planning Service (CHPS) compound in Ghana. https://bura.brunel.ac.uk/handle/2438/30902
72. Nyonator, F. K., Awoonor-Williams, J. K., Phillips, J. F., Jones, T. C., & Miller, R. A. (2002). The Ghana Community-based Health Planning and Services (CHPS) Initiative: Fostering Evidence-based Organizational Change and Development in a Resource-constrained Setting. Director, 9, 13 Nwameme, A. U., Tabong, P. T. N., & Adongo, P. B. (2018). Implementing community-based health planning and services in impoverished urban communities: health workers' perspective. BMC health services research, 18, 1-11. https://doi.org/10.1186/s12913-018-3005-1 Nyonator, F. K., Awoonor-Williams, J. K., Phillips, J. F., Jones, T. C., & Miller, R. A. (2005). The Ghana Community-based Health Planning and Services Initiative for scaling up service delivery innovation. In Health Policy and Planning (Vol. 20, Issue 1, pp. 25-34). https://doi.org/10.1093/heapol/czi003
73. Olayinka, F., O'Connell, T. S., Morgan, C., Monzon, M. F., Oshin, T., Tampe, T., ... & Shearer, J. C. (2024, July). Applying a Primary Health Care Approach to Closing the Human Resource for Health Gaps for Immunization. In Healthcare (Vol. 12, No. 14, p. 1449). MDPI.
74. Openstax (2024). Community-Based Healthcare Initiatives. https://openstax.org/books/fundamentals-nursing/pages/4-5-community-based-healthcare-initiatives - Accessed Date: 21/12/2024).
75. Owusu, L., Tuwor, R. D., Ackam, N., Loglo, A., Agbavor, B., Agbanyo, A., ... & Phillips, R. O. (2023). Role and capacity needs of community based surveillance volunteers in the integrated management of skin neglected tropical diseases (skin NTDs): a qualitative study from central Ghana. BMC Public Health, 23(1), 1086.
76. O'Toole Jr, L. J., & Meier, K. J. (2010). Implementation and managerial networking in the new public governance. In The New Public Governance? (pp. 338-352). Routledge.
77. Okine, P. E. N. A. (2024). An evaluation of community health care service in Ghana: A case of the Community-Based Health and Planning Service (CHPS) compound in Ghana (Doctoral dissertation, Brunel University London).
78. Park, S. (2022). The construction of social inequity and the role of public bureaucracies. Journal of Policy Studies (JPS), 37(4), 1-15. https://doi.org/10.52372/jps37401
79. Plano Clark, V. L. (2017). Mixed methods research. The Journal of Positive Psychology, 12(3), 305-306. https://doi.org/10.1080/17439760.2016.1262619
80. Pool, R., Montgomery, C. M., Morar, N. S., Mweemba, O., Ssali, A., Gafos, M., ... & McCormack, S. (2010). A mixed methods and triangulation model for increasing the accuracy of adherence and sexual behaviour data: the Microbicides Development Programme. PloS one, 5(7), e11600. https://doi.org/10.1371/journal.pone.0011600
81. Portero de la Cruz, S., Cebrino, J., Herruzo, J., & Vaquero-Abellán, M. (2020). A multicenter study into burnout, perceived stress, job satisfaction, coping strategies, and general health among emergency department nursing staff. Journal of clinical medicine, 9(4), 1007. https://doi.org/10.3390/jcm9041007
82. Prem, V., Karvannan, H., Kumar, S. P., Karthikbabu, S., Syed, N., Sisodia, V., & Jaykumar, S. (2012). Study of nurses' knowledge about palliative care: a quantitative cross-sectional survey. Indian journal of palliative care, 18(2), 122. https://doi.org/10.4103/0973-1075.100832
83. Perry, H. B., Chowdhury, M., Were, M., LeBan, K., Crigler, L., Lewin, S., ... & Hodgins, S. (2021). Community health workers at the dawn of a new era: 11. CHWs leading the way to "Health for All". Health research policy and systems, 19, 1-21.
84. Rifkin, S. B. (2014). Examining the links between community participation and health outcomes: a review of the literature. Health policy and planning, 29(suppl_2), ii98-ii106. https://doi.org/10.1093/heapol/czu076
85. Rivera, J. D., & Knox, C. C. (2023). Bureaucratic discretion, social equity, and the administrative legitimacy dilemma: Complications of New Public Service. Public Administration Review, 83(1), 65-77. https://doi.org/10.1111/puar.13550
86. Sakeah, E., Bawah, A. A., Asuming, P. O., Debpuur, C., Welaga, P., Awine, T., ... & Oduro, A. R. (2023). Impact of community health interventions on maternal and child health indicators in the upper east region of Ghana. BMC Pregnancy and Childbirth, 23(1), 298. https://doi.org/10.1186/s12884-023-05577-7
87. Saunders, B., Sim, J., Kingstone, T., Baker, S., Waterfield, J., Bartlam, B., ... & Jinks, C. (2018). Saturation in qualitative research: exploring its conceptualization and operationalization. Quality & quantity, 52, 1893-1907. https://doi.org/10.1007/s11135-017-0574-8
88. Sheikh, K., Ranson, M. K., & Gilson, L. (2014). Explorations on people centredness in health systems. Health policy and planning, 29(suppl_2), ii1-ii5. https://doi.org/10.1093/heapol/czu082
89. Sumah, A. M., & Baatiema, L. (2018). Decentralisation and management of human resource for health in the health system of Ghana: a decision space analysis. International journal of health policy and management, 8(1), 28. https://doi.org/10.15171/ijhpm.2018.88
90. Schwarz, D., Kim, J. H., Ratcliffe, H., Bell, G., Awoonor-Williams, J. K., Nimako, B., ... & Bitton, A. (2019). The status of Ghanaian community health workers' supervision and service delivery: descriptive analyses from the 2017 Performance Monitoring and Accountability 2020 survey. Gates Open Research, 3, 1468. https://doi.org/10.12688/gatesopenres.12979.2
91. Teram, E., & White, H. (1993). Strategies to address the bureaucratic disentitlement of clients from cultural minority groups. Canadian Journal of Community Mental Health, 12(2), 59-70. https://doi.org/10.7870/CJCMH-1993-0018
92. Teye, J. K., Yaro, J. A., & Bawakyillenuo, S. (2015). Local farmers' experiences and perceptions of climate change in the Northern Savannah zone of Ghana. International Journal of Climate Change Strategies and Management, 7(3), 327-347. https://doi.org/10.1108/IJCCSM-05-2014-0066
93. Thomann, E., & Lieberherr, E. (2023). Bringing street-level bureaucrats' behaviour into policy evaluation. In Handbook of Public Policy Evaluation (pp. 391-407). Edward Elgar Publishing. https://doi.org/10.4337/9781800884892.00035 Tierozie, C. (2011). Impact assessment of the community-based health planning and services initiative in the Berekum municipality (Doctoral dissertation).
94. Tummers, L. L., Bekkers, V., Vink, E., & Musheno, M. (2015). Coping during public service delivery: A conceptualization and systematic review of the literature. Journal of Public Administration Research and Theory, 25(4), 1099-1126. https://doi.org/10.1093/jopart/muu056
95. Tummers, L., & Bekkers, V. (2014). Policy implementation, street-level bureaucracy, and the importance of discretion. Public Management Review, 16(4), 527-547. https://doi.org/10.1080/14719037.2013.841978
96. Universiteit, P. A.-V., & 2017, undefined. (2016). ACCESS TO HEALTHCARE THROUGH NHIS; FACTORS LIMITING ENROLMENT OF THE POOR UNTO THE NATIONAL HEALTH INSURANCE SCHEME IN. Bibalex.Org. http://bibalex.org/baifa/Attachment/Documents/aOac5ijpgw_20180415123208956.pdf
97. Van Belle, S., & Mayhew, S. H. (2016). Public accountability needs to be enforced-a case study of the governance arrangements and accountability practices in a rural health district in Ghana. BMC health services research, 16, 1-14. https://doi.org/10.1186/s12913-016-1836-1
98. Wak, G., Oladokun, S., Manye, A., Awine, T., Komesuor, J., & Aborigo, R. (2025). Effect of Household Dynamics on Infant Mortality in the Kassena_Nankana Districts of Rural Northern Ghana, 1999-2018. Child Indicators Research, 1-18.
99. World Health Organization. (2016). Framework on integrated, people-centred health services. Geneva: World Health Organization, 2019.
100. World Health Organization. (2018). WHO guideline on health policy and system support to optimize community health worker programmes. World Health Organization.
101. Wu, X., Wang, H., Yuan, X., Huang, S., & Luo, D. (2015). Design and implementation of recursive model predictive control for permanent magnet synchronous motor drives. Mathematical Problems in Engineering, 2015(1), 431734. https://doi.org/10.1155/2015/431734
102. Wak, G., Oladokun, S., Manye, A., Awine, T., Komesuor, J., & Aborigo, R. (2025). Effect of Household Dynamics on Infant Mortality in the Kassena_Nankana Districts of Rural Northern Ghana, 1999-2018. Child Indicators Research, 1-18. https://doi.org/10.1007/s12187-024-10212-8
103. Wagenaar, H. (2019). Discretion and street-level practice. In Discretion and the quest for controlled freedom (pp. 259-277). Cham: Springer International Publishing. https://doi.org/10.1007/978-3-030-19566-3_17
104. Yin, Robert K. (2017). Case study research and applications: Design and methods. Sage Publications.
105. Zulu, J. M., & Perry, H. B. (2021). Community health workers at the dawn of a new era. Health Research Policy and Systems, 19, 1-5.