Community engagement | Traditional and secular leaders support community-based primary health care.74,75 | Implementation milestones were documented that included mapping and “community entry.” |
Gatherings (durbars) contribute to community support.75 | Durbars are recognized as effective means of consensus building for community action. |
Gender problems prevented access to care and women’s inability to realize their reproductive preferences.76 | Gender development strategies are essential to the implementation of services that depend upon women’s individual agency. |
Financing | Service financing: “Trust as insurance:” Payment of “cash-and-carry” fees deferred for episodes of care, based on nurse trust that extended families would eventually reimburse the program. | None. |
Start-up costs: The start-up cost of adding community services to the existing program was less than $10 per capita. Communities will construct interim health post facilities at minimal cost, expediting implementation.75 | Start-up costs not budgeted until 2009. Delayed response: Table 3. |
Nurse training, deployment, and management | Existing nurse training programs were urban based; CHN tended to be unfamiliar with rural residence and norms. | Localized recruitment and training tested and shown to be more effective than centralized training |
Training omitted modules on community engagement. | A 6-month internship and training module added. CHNs completing this certification redesignated as CHOs. |
Ghana has 82 languages: CHN were not always deployed in areas where they spoke local languages. | District-level recruitment, training, and deployment. |
Nurses were ineffective family planning service providers if posted to their ancestral community because residents were concerned about possible breaches in confidentiality if providers were members of informal social networks.75,76 | Deployment to localities based on language ability; deployment to home communities was avoided. |
Essential equipment procurement and operation | Motorcycles were affordable, but district maintenance capabilities were lacking. Nurses were relocated from clinic residencies where their families were also based. | Logistics development was organized. Nurses were trained in motorcycle use and basic maintenance. Fuel delivered to nurses during supervisory outreach rounds. |
Essential drugs: Nurse deployment accelerated the volume of primary care encounters, depleting pharmaceutical supplies. | Logistics reform factored in acceleration of supply requirements. |
Volunteer recruitment, deployment, and management | Volunteer recruitment and deployment is feasible. Volunteers were effective in providing outreach to men. | Volunteers recruited in conjunction with CHO deployment; CHO consigned supervisory and community engagement functions. |
Supervision and management: Community-based care amplified the need for supervisory outreach. | District CHPS coordinators added to the CHPS staffing structure with CHO, CHVs, and CHMCs. |