Journal of Community Health

, Volume 41, Issue 2, pp 398–408 | Cite as

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

  • Katharine D. ShelleyEmail author
  • Yekoyesew W. Belete
  • Sydney Chauwa Phiri
  • Mutinta Musonda
  • Elizabeth Chizema Kawesha
  • Evelyn Mutinta Muleya
  • Caroline Phiri Chibawe
  • Jan Willem van den Broek
  • Kathryn Bradford Vosburg
Original Paper


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.


Community health workers Human resources for health Qualitative process evaluation Zambia Health systems strengthening 



The process evaluation was made possible through funding support from UKAid/DFID of the UK Government. The authors would like to acknowledge the collaborative support of the Zambian Ministry of Health and Ministry of Community Development, Mother and Child in carrying out the process evaluation. We would also like to thank all interview participants, including the staff of the participating District Health Offices and health facilities, for sharing their invaluable perspectives on the rollout of the CHA program. The field interview team of Nomsa Manda, Lungowe Lubaba, and Makasa Chilatu are acknowledged for conducting interviews and providing transcription support. We thank our colleagues at DFID, particularly Meena Gandhi, for their support and feedback through this evaluation and in the implementation of the program. During the process evaluation design stage, we are thankful for the technical support on qualitative research methods provided by Dr. Bobbie Person (CDC). The staff of the CHAI Zambia office is greatly acknowledged for their logistical support throughout the evaluation. Special thanks to Margaret Lippitt Prust for her review and input on the manuscript. The views expressed in this article are the opinions of the authors and do not necessarily reflect the official policies of DFID or the UK Government.

Author Contributions

KBV, YWB, and MM conceived of the process evaluation assessment. YWB and KDS drafted the process evaluation protocol and designed the data collection tools with input from KBV and MM. KDS, YWB, and the field interviewers collected and transcribed all interview data; KDS and YWB analyzed the data and jointly drafted a programmatic report documenting all evaluation results and recommendations. KBV and YWB worked with ministry counterparts (MM, ECK, EMM and CPC) to share process evaluation results and discuss recommended actions. KDS wrote the first draft of the manuscript; YWB, KBV, JWvdB and SP provided substantial revisions. All co-authors reviewed and approved the final manuscript.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.


This research was supported by the UK Department for International Development (DFID) through C.C. 200667-102 P/O 40034923.


  1. 1.
    Murphy, G. T., Goma, F., MacKenzie, A., Bradish, S., Price, S., Nzala, S., et al. (2014). A scoping review of training and deployment policies for human resources for health for maternal, newborn, and child health in rural Africa. Human Resources for Health, 12(1), 72.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    WHO. (2006). Working together for health: World health report 2006. Geneva, Switzerland: WHO.Google Scholar
  3. 3.
    Lehmann, U., & Sanders, D. (2007). Community health workers: What do we know about them?. Geneva, Switzerland: WHO.Google Scholar
  4. 4.
    Tulenko, K., Møgedal, S., Afzal, M. M., Frymus, D., Oshin, A., Pate, M., et al. (2013). Community health workers for universal health-care coverage: From fragmentation to synergy. Bulletin of the World Health Organization, 91(11), 847–852.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    WHO. (2013). The world health report 2013: Research for universal health coverage. Geneva, Switzerland: WHO.Google Scholar
  6. 6.
    Campbell, J., Admasu, K., & Tlou, S. (2015). Maximizing the impact of community-based practitioners in the quest for universal health coverage. Bulletin of the World Health Organization, 93, 590.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Perry, H. B., Zulliger, R., & Rogers, M. M. (2014). Community health workers in low-, middle-, and high-income countries: An overview of their history, recent evolution, and current effectiveness. Annual Review of Public Health, 35, 399–421.CrossRefPubMedGoogle Scholar
  8. 8.
    WHO. (1989). Strengthening the performance of community health workers in primary health care. Technical report series 780. Geneva, Switzerland.Google Scholar
  9. 9.
    Perry, H., & Crigler, L. (2014). Developing and strengthening community health worker programs at scale: Guidance for program managers and policy makers. Washington, DC: USAID, MCHIP.Google Scholar
  10. 10.
    CIA. (2014). Zambia. The World Factbook. Retrieved from
  11. 11.
    Institute for Health Metrics and Evaluation. (2013). Global burden of disease country profile: Zambia. Seattle, Washington. Retrieved from
  12. 12.
    UNAIDS. (2015). How AIDS changed everythingMDG 6: 15 years, 15 lessons of hope from the AIDS response. Retrieved from
  13. 13.
    WHO. (2014). World malaria report 2014. Retrieved from
  14. 14.
    Zambia Central Statistical Office. (2013). Zambia demographic and health survey 20132014: Preliminary report. Retrieved from
  15. 15.
    Kamwanga, J., Koyi, G., Mwila, J., Musonda, M., & Bwalya, R. (2013). Understanding the labour market of human resources for health in Zambia.Google Scholar
  16. 16.
    Ferrinho, P., Siziya, S., Goma, F., & Dussault, G. (2011). The human resource for health situation in Zambia: Deficit and maldistribution. Human Resources for Health, 9(1), 30.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Gow, J., George, G., Mutinta, G., Mwamba, S., & Ingombe, L. (2011). Health worker shortages in Zambia: An assessment of government responses. Journal of Public Health Policy, 32(4), 476–488.CrossRefPubMedGoogle Scholar
  18. 18.
    MOH Zambia. (2009). Concept note for the development of a community health worker national strategy. Lusaka, Zambia: MOH Zambia.Google Scholar
  19. 19.
    MOH Zambia. (2010). National community health worker strategy in Zambia. Lusaka, Zambia: MOH Zambia.Google Scholar
  20. 20.
    Zulu, J. M., Kinsman, J., Michelo, C., & Hurtig, A.-K. (2013). Developing the national community health assistant strategy in Zambia: A policy analysis. Health Research Policy and Systems/BioMed Central, 11(1), 24.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Rossi, P. H., Lipsey, M. W., & Freeman, H. E. (2004). Tailoring evaluations. Evaluation: A systematic approach (7th ed., pp. 31–65). Thousand Oaks, CA: SAGE Publications.Google Scholar
  22. 22.
    Hulscher, M., Laurant, M., & Grol, R. (2003). Process evaluation on quality improvement interventions. Quality and Safety in Health Care, 12(1), 40–46.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Carroll, C., Patterson, M., Wood, S., Booth, A., Rick, J., & Balain, S. (2007). A conceptual framework for implementation fidelity. Implementation Science, 2, 40.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    MOH Zambia. (2011). Republic of Zambia: National human resources for health strategic plan 2011–2015. Lusaka, Zambia: MOH Zambia.Google Scholar
  25. 25.
    MOH Zambia. (2013). The 2012 List of Health Facilities in Zambia: Preliminary Report, v15. Lusaka: Zambia.Google Scholar
  26. 26.
    NCH Software, version 5.63. (2013). Express scribe. Canberra, Australia: NHC Software. Retrieved from
  27. 27.
    VERBI Software – Consult – Sozialforschung GmbH. (2013). MAXQDA, software for qualitative data analysis, 19982014. Berlin, Germany.Google Scholar
  28. 28.
    Zhang, Y., & Wildermuth, B. M. (2005). Qualitative analysis of content. Analysis, 1(2), 1–12.Google Scholar
  29. 29.
    Zulu, J. M., Kinsman, J., Michelo, C., & Hurtig, A.-K. (2014). Integrating national community-based health worker programmes into health systems: A systematic review identifying lessons learned from low-and middle-income countries. BMC Public Health, 14(1), 987.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Zulu, J. M., Kinsman, J., Michelo, C., & Hurtig, A.-K. (2014). Hope and despair: Community health assistants’ experiences of working in a rural district in Zambia. Human Resources for Health, 12(1), 30.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Zulu, J. M., Hurtig, A.-K., Kinsman, J., & Michelo, C. (2015). Innovation in health service delivery: Integrating community health assistants into the health system at district level in Zambia. BMC Health Services Research, 15(1), 1–12.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Katharine D. Shelley
    • 1
    • 3
    Email author
  • Yekoyesew W. Belete
    • 2
    • 3
  • Sydney Chauwa Phiri
    • 3
  • Mutinta Musonda
    • 4
    • 7
  • Elizabeth Chizema Kawesha
    • 5
  • Evelyn Mutinta Muleya
    • 6
  • Caroline Phiri Chibawe
    • 7
  • Jan Willem van den Broek
    • 3
  • Kathryn Bradford Vosburg
    • 3
  1. 1.Department of International HealthJohns Hopkins University Bloomberg School of Public HealthBaltimoreUSA
  2. 2.MDG Acceleration Initiative, UNICEFLusakaZambia
  3. 3.Clinton Health Access InitiativeLusakaZambia
  4. 4.Human Resources AdministrationMinistry of Foreign AffairsLusakaZambia
  5. 5.Disease Surveillance, Research and ControlMinistry of HealthLusakaZambia
  6. 6.Human Resources and AdministrationMinistry of HealthLusakaZambia
  7. 7.Mother and Child HealthMinistry of Community Development, Mother and Child HealthLusakaZambia

Personalised recommendations