Hope and despair: community health assistants’ experiences of working in a rural district in Zambia

Abstract

BackgroundIn order to address the challenges facing the community-based health workforce in Zambia, the Ministry of Health implemented the national community health assistant strategy in 2010. The strategy aims to address the challenges by creating a new group of workers called community health assistants (CHAs) and integrating them into the health system. The first group started working in August 2012. The objective of this paper is to document their motivation to become a CHA, their experiences of working in a rural district, and how these experiences affected their motivation to work.MethodsA phenomenological approach was used to examine CHAs’ experiences. Data collected through in-depth interviews with 12 CHAs in Kapiri Mposhi district and observations were analysed using a thematic analysis approach.ResultsPersonal characteristics such as previous experience and knowledge, passion to serve the community and a desire to improve skills motivated people to become CHAs. Health systems characteristics such as an inclusive work culture in some health posts motivated CHAs to work. Conversely, a non-inclusive work culture created a social structure which constrained CHAs’ ability to learn, to be innovative and to effectively conduct their duties. Further, limited supervision, misconceptions about CHA roles, poor prioritisation of CHA tasks by some supervisors, as well as non- and irregular payment of incentives also adversely affected CHAs’ ability to work effectively. In addition, negative feedback from some colleagues at the health posts affected CHA’s self-confidence and professional outlook. In the community, respect and support provided to CHAs by community members instilled a sense of recognition, appreciation and belonging in CHAs which inspired them to work. On the other hand, limited drug supplies and support from other community-based health workers due to their exclusion from the government payroll inhibited CHAs’ ability to deliver services.ConclusionsProgrammes aimed at integrating community-based health workers into health systems should adequately consider multiple incentives, effective management, supervision and support from the district. These should be tailored towards enhancing the individual, health system and community characteristics that positively impact work motivation at the local level if such programmes are to effectively contribute towards improved primary healthcare.

Implementation of the Community Health Assistant (CHA) Cadre in Zambia: A Process Evaluation to Guide Future Scale-Up Decisions

“…CHAs, supervisors, and district focal leaders consistently mentioned two underlying problems at program launch: a lengthy delay in CHA receiving monthly salaries and the inability of CHAs to access drugs and commodities through the national supply chain. These are consistent with a recent qualitative study of CHAs' work experiences [30], and suggest that the government health system was unable to react quickly enough to incorporate the new cadre. For example, even after the 1-week CHA training course for CHA supervisors, additional memos from the MOH to the provincial and district-levels were necessary to ensure that CHAs could access commodities from the RHC.…”

Effect of deploying community health assistants on appropriate treatment for diarrhoea, malaria and pneumonia: quasi‐experimental study in two districts of Zambia

“…The lack of observed health impact could possibly be explained by demotivation, inadequate supportive supervision, inadequate logistical support and lack of medical supplies for outreach activities. Many of these challenges in the early days of the CHA programme have been documented in other studies, and have already been or are currently being addressed [23]. Findings from a process evaluation conducted by the CHAI and the MOH and Ministry of Community Development, Mother and Child Health (MCDMCH), which was conducted at CHA sites not included in this study confirmed many of the issues observed in our contextual data gathering, including delays in salary payments for CHAs, shortages of drugs and supplies, challenges with transport, lack of incorporation of the CHA programme into district planning documents and limited supportive supervision [24].…”

Motivation of health surveillance assistants in Malawi: A qualitative study

“…A CHW can be based in the community or in a basic primary health care facility. In addition to specific aspects of their job descriptions, CHW selection criteria, remuneration and incentives, training, supervision, and support structures vary by country and depend in part on the extent to which CHWs are integrated into a health system, 3,4 as well as on the degree to which task shifting has been implemented. 5 There has been growing global interest in assessing how motivation shapes performance of CHWs.…”