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

Abstract

Universal health coverage requires an adequate health workforce, including community health workers (CHWs) to reach rural communities. To improve healthcare access in rural areas, in 2010 the Government of Zambia implemented a national CHW strategy that introduced a new cadre of healthcare workers called community health assistants (CHAs). After 1 year of training the pilot class of 307 CHAs deployed in September 2012. This paper presents findings from a process evaluation of the barriers and facilitators of implementation of the CHA pilot, along with how evidence was used to guide ongoing implementation and scale-up decisions. Qualitative inquiry was used to assess implementation during the first 6 months of the program rollout, with 43 in-depth individual and 32 small group interviews across five respondent types: CHAs, supervisors, volunteer CHWs, community members, and district leadership. Potential 'implementation moderators' were explored using deductive coding and thematic analysis of participant perspectives on community acceptance of CHAs, supervision support mechanisms, and coordination with volunteer CHWs, and health system integration of a new cadre. Community acceptance of CHAs was generally high, but coordination between CHAs and existing volunteer CHWs presented some challenges. The supervision support system was found to be inconsistent, limiting assurance of consistent quality care delivered by CHAs. Underlying health system weaknesses regarding drug supply and salary payments furthermore hindered incorporation of a new cadre within the national health system. Recommendations for implementation and future scale based on the process evaluation findings are discussed.

An exploration of facilitators and challenges in the scale-up of a national, public sector community health worker cadre in Zambia: a qualitative study

“…Within the first 6 months after deployment, a process evaluation was carried out to identify the implementation barriers and facilitators to the incorporation of this new health cadre within the national health system in Zambia [5]. This evaluation showed that community acceptance of CHAs was generally high but coordination between CHAs and existing CHWs presented some challenges.…”

Partnering with traditional Chiefs to expand access to cervical cancer prevention services in rural Zambia

“…Scale‐up of CCPPZ has mainly concentrated on the capital city of Lusaka . However, the National Cancer Control Strategic Plan of Zambia called for similar services to be implemented in rural areas of the country, where 60% of the population resides . Severe human and infrastructure resource gaps have historically hindered the implementation of cervical cancer prevention services in rural Zambia, compounded by myths and misconceptions surrounding this disease and its treatment .…”

“…7 However, the National Cancer Control Strategic Plan of Zambia called for similar services to be implemented in rural areas of the country, where 60% of the population resides. [8][9][10][11] Severe human and infrastructure resource gaps have historically hindered the implementation of cervical cancer prevention services in rural Zambia, compounded by myths and misconceptions surrounding this disease and its treatment. 12 To overcome these barriers, local Chiefs (a traditional sector of Zambian civil society) were engaged to gain access to the target population.…”

Task-shifting impact of introducing a pilot community health worker cadre into Zambia’s public sector health workforce

“…In 2010, the Ministry of Health (MOH) launched a National Community Health Worker Strategy with the goal of deploying an effective, well-trained, and motivated cadre to improve maternal and child health in rural areas. The scope of work for these Community Health Assistants (CHAs) includes preventative and basic curative services with complicated patient cases referred from the community-level to higher-level health workers based at nearby health facilities [ 12 ]. CHAs are nominated by their communities and return home to start providing care after one year of formal training.…”

“…While the initial funding for CHA remuneration was supported by development aid partners, the CHAs were transitioned to the public sector payroll and thus fully integrated into the public sector health workforce in December 2013. The CHA scope of work and challenges in their initial community deployments are described in detail in by Shelley et al in their findings of a 2012–2013 process evaluation of the CHA program to guide future scale-up decisions [ 12 ].…”