Table 2 Key lessons learned from ‘Phase 1’: the urban pilot and research activities

The provision of essential health services and technologies

The burden of disease

The rural burden of disease is dominated by three causes of childhood morbidity and mortality: malaria, acute respiratory infections, and diarrheal diseases.

The disease burden is much more diverse in urban locations. Although the disease transition is underway, a large part of the population remains impoverished and susceptible to infectious diseases. Considerably, urban health planning must cater for infectious-, chronic-, trauma-, and injury-related morbidity. Furthermore, the high concentration of adolescents in urban areas means that sexually transmitted infections are of serious concern.

The role of health campaigns

In rural settings, the CHPS program frequently utilizes disease-specific health campaigns, such as mass immunization days or entire cadre focused on particular modalities or syndromes of illness.

Need to consider the diverse burden of disease in the urban context, as well as the lack of seasonality – the vertical campaign-based system is not relevant.

The provision of ‘doorstep’ care

Doorstep services are needed for family planning service effectiveness, but less needed for the provision of ambulatory child health service.

The ‘doorstep model’, which is central to rural CHPS operations, proved inappropriate within the urban context. Much of the population are in full-time employment during the day and were not present for these home visits. To accommodate for this, the CHPS nurses began providing evening and weekend home visiting schedules.

Use of specialised outreach services, visiting available for mutual groups on designated days.

The provision of family planning and reproductive health services

Unmet need for spacing comprises nearly all of the demand for services.

The urban population had more interest in using family planning for limiting rather than childbearing as typically observed in rural populations.

Extending service access

Private facilities and services are less important than the Ghana Health Service public sector program.

The urban populations were more likely to utilize private sources, such as pharmacy shops and other drug vendors when seeking for health resources. The public sector plays a much less prominent role than in rural communities.

Manpower, training, and deployment

Training of nurses

Training should be focused on the Integrated Management of Childhood Illness and family planning. Midwifery training is important as result of greater likelihood of home-based delivery.

Urban nurses should focus more on adolescent and adult health needs, in addition to chronic diseases and sanitation. There should also be a greater emphasis on in-service trainings, due to the breadth of competencies required in working with this disease-diverse population. Midwifery is also of less importance for urban nurses due to the greater likelihood for facility-based deliveries.

Volunteer involvement

Appropriate engagement of traditional leaders can facilitate sustainable volunteerism.

Engagement and support of volunteers remains at the core of the CHPS model. Urban volunteers, however, indicated that compensation was necessary for their participation, due to the greater opportunity costs for their involvement, thus challenging the traditional CHPS volunteer paradigm.

Involving men in family planning is crucial to success; volunteers can play an essential role in developing male mobilization and participation in family planning.

Individual men are more accepting of family planning in urban areas, obviating the need for group outreach; volunteer outreach to male social networks does not work in the urban context.

Information for decision-making

Mobile-Health (m-health) for health service support

Cell phone connectivity is a problem in rural areas; cell phone information services to rural women often fails to connect with intended recipients.

Cell phones are ubiquitous and functional; gender problems that hamper access in rural areas are less relevant to the urban context.

Essential supplies and logistics

Resolve access problems by solving logistical challenges

Motorbikes and bicycles are required for supporting ‘doorstep’ services.

The established CHPS model requires nurses to remain resident at the CHPS health post. This precedent, however, proved difficult due to the more expensive nature of urban real estate. The provision of accommodation for nurses was costly, and financial constraints required for the rental rather than purchase of health post property.

Essential resources and planning

Health insurance

Trust arrangements permit workers to provide services with the understanding that extended families will eventually reimburse providers for commodity costs.

Traditional ‘trust as insurance’ arrangements do not work in the urban context. There is much higher coverage of the national health insurance programme in urban areas. These populations therefore seek health services directly from public facilities. Home-based (‘doorstep’) care is not always supported by health insurance, which questions its appropriateness for this population.

Organizational capacity

Rural setting offer opportunity for stable population.

The urban setting offered increased opportunities to mobilize populations, including through youth groups, women’s market associations, beauticians, unions, political entities, and church organizations.

Leadership and governance

The role of Health Committees

Existing mechanisms for social organization, networks, and lineal structures can be marshalled for organizing the governance of primary health care operations.

Health committees (HCs), which include community representatives from the designated CHPS zone, are central to CHPS development and operations. In the urban context, HCs lack the influences of traditional social structures, including tribal leadership. In the absence of such arrangements, local politics plays a much greater role in the formation of HCs. In addition, the HCs sought for greater authority and for the provision of a permanent location to operate from. For example, the HCs sought the power to be able to give out sanctions to individuals that violated established sanitation standards within their communities.

Developing community support

Communities will organize leadership for CHPS and construction of health posts.

Although there was extensive support for the introduction of the CHPS project in pilot communities, actual participation was sporadic and disorganized. This was likely due to the lack of traditional chieftaincy and lineage systems and ethnic diversity, resulting in challenges in mobilizing collective action.

The social context

Existing social institutions can be used for organizing services and simplifying outreach. Women will commit time to activities that involve existing social groups.

Opportunity costs are high for urban women and every family member must contribute financially. This results in serious time constraints for urban women. Childcare needs are great, especially in the absence of extended family networks. Furthermore, this lack of familial support results in less social protection, including child protection and social insurance, in addition to increased social discord and crime.

Adapting strategy to the gender context

Rural women are often dependent on males for key decisions and economically.

Urban households are often more dependent on women. Women often hold an economic role within their families, and often times heading their households. Marital dissolution is more common in urban locations.