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.
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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.
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.
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.
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Shelley, K.D., Belete, Y.W., Phiri, S.C. et al. Implementation of the Community Health Assistant (CHA) Cadre in Zambia: A Process Evaluation to Guide Future Scale-Up Decisions. J Community Health 41, 398–408 (2016). https://doi.org/10.1007/s10900-015-0110-5
- Community health workers
- Human resources for health
- Qualitative process evaluation
- Health systems strengthening