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Table 6 Primary health care policies, community experience with services, and program implications

From: A qualitative appraisal of stakeholders’ perspectives of a community-based primary health care program in rural Ghana

Capabilities mandated by official policies: Respondent perceptions of primary health care capabilities: Examples of possible program responses:
General system capabilities:
Medical procedures that require specialists:
Blood transfusion, surgery, caesarean sections, medical scans
Some discussants expect such services to be provided by CHPS Expand community education about services that are appropriately provided at each level.
Hospital personnel: Medical doctor available Some respondents requested access to personnel with a higher skills than existing nurses Develop and promote an affordable emergency referral system
Staffing of sub-district clinics: Clinics have the full range of paramedical staff posted to facilities including medical assistants, midwives and registered nurses More staff should be posted to Sub-district Health Centers. Most facilities have only two types of nurses and many lack medical assistants. Conduct a total district systems appraisal: Review staffing policy, training norms, and implementation strategies at each level of the system.
CHPS capabilities:
ĴStaffing
  One midwife with one or two Community Health Officers in each service zone CHPS facilities do not always have the full complement of CHOs. Many CHPS facilities lack midwives. The Ghana Health Service is expanding midwife training and deployment. However, consideration of training CHO as interim birth attendants is warranted.
CHPS patient relations:
  • Prioritize patients coming from afar First come first served In-service training on client relations is urgently needed [12]
  • Patient oriented staff attitudes Some discussants encountered rude and impersonal care
  • Staff responsive to emergency situations Discussants noted that CHPS care is not always available after office hours. There is a need for time-use analysis and a revised policy statement on worker hours of access.
   CHPS logistics:
  The facility has space to ensure privacy and reasonable comfort for its clientele Limited space in CHPS facilities, particularly in temporary facilities. Interim CHPS facilities are being replaced by properly constructed facilities. Plans and prospects should be communicated to communities to ensure involvement.
  Emergency service capabilities Few communities are reached by ambulances. Community engagement is lacking. Urgently needed scale-up is needed, based on successful demonstration of emergency care [13].
Pregnancy related CHPS services
  • Delivery of all types of pregnancies Delivery of uncomplicated pregnancies only; emergency obstetric care is often unavailable. Scale-up emergency referral systems. Improve community-engagement in referral operations [14]
  • ANC, PNC, CWC (No deviation from expectations) The high coverage of ANC should be combined with worker immediate post-partum follow-up procedures and mortality audit methods that are restricted to facility delivery [8]
  • Availability of all GHS essential drugs at CHPS facilities Limited range of essential drugs; limited capacity to administer first aid Conduct a comprehensive review of logistics and supply operations [15]
CHPS family planning services:
  Comprehensive doorstep and CHPS facility-based family planning information and care Family planning services in facilities only; limited community communication activities or household services.
Absence of outreach to men
Review strategies of experimental projects and pilot studies that successfully introduced and sustained family planning [16]
Implement proven male involvement strategies [17]
CHPS worker deployment and time use:
  CHPS never “closes”: Services are available on weekends, emergency services by resident CHO are available for 24 h, and clinical service hours start at 6 am. • Services are usually limited to week days and routine office hours.
• CHPS services are available for eight hours and unavailable at night.
• Usual work hours start at 8 am to 9 am
Develop a revised policy on work hours and facilitative supervision that clarifies CHO coverage hours [18]
Other expectations
 • Outreach and services that promote accessible safe water and sanitation Limited focus on community water and sanitation Develop community outreach that utilizes traditional communication mechanisms for consensus building and social action
 • Addressing social discord or spousal problems that restrict access to CHPS care. Gender and social problems are neglected. Revisit CHPS strategies that successfully engaged communities in program governance and action [19, 20]. Build total social system outreach as a core organizing strategy of CHPS [21]
  1. Source: CHPS+ qualitative data, 2017