TABLE 1.

Pragmatic Observations Associated With the Navrongo Phase 1 Pilot to Increase Access to Primary Health Care Services, Ghana

Program Component	Observation of Pilot Investigators	National Policy Outcome
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.
Financing	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 equipment procurement and operation	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.
Volunteer recruitment, deployment, and management	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.

Abbreviations: CHMC, community health management committee; CHN, community health nurse; CHO, community health officer; CHPS, Community-based Health Planning and Services; CHV, community health volunteers.