Deficient range of services. Community health officers (CHOs) were unprepared for essential services (midwifery, emergency management, immediate post-delivery care).

Over-extension of job descriptions

Piloted and scaled up community-engaged referral system

Trained CHOs in strategies for saving newborn lives

Focus roles on the burden of disease and family planning

Risk transition. Community-based primary health care reduces the burden of disease. Emergency-related causes comprise an increased proportion of the remaining unaddressed burden.

Community-based planning. Developing effective referral systems requires adapting operations to community road conditions and communication needs.

Insufficient nurse manpower

Centralized recruitment results in deployment of workers to localities where they are not conversant with local languages or customs.

Expanded nurse training school volume

Recruited trainees from districts where they are to be assigned and involved health committees in selection process

Bottom-up planning. Community health systems development requires “bottom up” strategic planning so that scale up builds capacity that effectively links services to local cultural conditions, languages, and health needs.

Plan for ethnic diversity. Community-engaged recruitment reduces turnover and improves performance, morale, and community ownership.

Pre-service training. Existing 18-month training program does not address community engagement, service outreach, and community health care planning. Overreliance on didactic training and shortage of locations and equipment for mentoring arrangements hinder CHO preparedness.

In-service training. Relocating nurses from clinics to villages requires training them to be community organizers with liaison and diplomatic skills.

Implemented 6-month regional CHO internships focused on community engagement

Organized peer mentoring coordinated with the training school curriculum

Systems approach to manpower development. Equipment and budgetary planning should integrate the process of pre-service, internship, and in-service training and plan for peer-mentoring arrangements.

Community-engaged peer leadership. Didactic health technology training is insufficient.

Insufficient programmatic focus on household services; health posts are the main service point.

The National Health Insurance Scheme (NHIS) incentivized static services at the expense of doorstep care, reducing access.

NHIS reimbursement for the provision of clinical services de-emphasizes supervisory outreach.

Developed supervisory work routines that are independent of NHIS reimbursement rules

Systems approach to CHO deployment, monitoring, and supervision. Programs that focus narrowly on a single community health worker cadre, health problem, or function are risky. “Learning localities” are needed where systems functioning is comprehensively monitored and where lessons learned are communicated to senior officials.

Compatibility of reimbursement schemes with doorstep care. National Health Insurance schemes require careful trial of their impact on non-clinic based community-based service operations.

Volunteers providing antipyretics can inadvertently delay parental health-seeking behavior, elevating risk. With careful training and supervision, however, volunteers can provide integrated management of childhood illness (IMCI).

Training volunteers in social engagement methods is essential.

Female health volunteers are more committed to service activities than male volunteers, but male volunteers are critical to family planning promotion.

Risk mitigation with field research: Reliance on untested imported initiatives is risky.

Partial IMCI does not work: Volunteer services can cause more harm than good unless volunteer deployment is coordinated with deployment of trained nurses and governed by rigorous supervision.