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Developing the national community health assistant strategy in Zambia: a policy analysis
Department of Public Health, School of Medicine, University of Zambia, Lusaka, Zambia .
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.ORCID iD: 0000-0003-1332-4138
Department of Public Health, School of Medicine, University of Zambia, Lusaka, Zambia .
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.ORCID iD: 0000-0001-7087-1467
2013 (English)In: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 11, 24- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: In 2010, the Ministry of Health in Zambia developed the National Community Health Assistant strategy, aiming to integrate community health workers (CHWs) into national health plans by creating a new group of workers, called community health assistants (CHAs). The aim of the paper is to analyse the CHA policy development process and the factors that influenced its evolution and content. A policy analysis approach was used to analyse the policy reform process.

METHODOLOGY: Data were gathered through review of documents, participant observation and key informant interviews with CHA strategic team members in Lusaka district, and senior officials at the district level in Kapiri Mposhi district where some CHAs have been deployed.

RESULTS: The strategy was developed in order to address the human resources for health shortage and the challenges facing the community-based health workforce in Zambia. However, some actors within the strategic team were more influential than others in informing the policy agenda, determining the process, and shaping the content. These actors negotiated with professional/statutory bodies and health unions on the need to develop the new cadre which resulted in compromises that enabled the policy process to move forward. International agencies also indirectly influenced the course as well as the content of the strategy. Some actors classified the process as both insufficiently consultative and rushed. Due to limited consultation, it was suggested that the policy content did not adequately address key policy content issues such as management of staff attrition, general professional development, and progression matters. Analysis of the process also showed that the strategy might create a new group of workers whose mandate is unclear to the existing group of health workers.

CONCLUSIONS: This paper highlights the complex nature of policy-making processes for integrating CHWs into the health system. It reiterates the need for recognising the fact that actors' power or position in the political hierarchy may, more than their knowledge and understanding of the issue, play a disproportionate role in shaping the process as well as content of health policy reform.

Place, publisher, year, edition, pages
BioMed Central, 2013. Vol. 11, 24- p.
Keyword [en]
Human resources, National community health assistant strategy, Policy analysis, Zambia
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-79587DOI: 10.1186/1478-4505-11-24ISI: 000322277600001PubMedID: 23870454OAI: oai:DiVA.org:umu-79587DiVA: diva2:643132
Available from: 2013-08-26 Created: 2013-08-26 Last updated: 2017-12-06Bibliographically approved
In thesis
1. Integration of national community-based health worker programmes in health systems: Lessons learned from Zambia and other low and middle income countries
Open this publication in new window or tab >>Integration of national community-based health worker programmes in health systems: Lessons learned from Zambia and other low and middle income countries
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: To address the huge human resources for health (HRH) crisis that Zambia and other low and middle income countries (LMICs) are experiencing, most LMICs have engaged the services of small scale community-based health worker (CBHW) programmes. However, several challenges affect the CBHWs’ ability to deliver services. Integration of national CBHW programmes into health systems is an emerging innovative strategy for addressing the challenges. Integration is important because it facilitates recognition of CBHWs in the national primary health care system. However, the integration process has not been optimal, and a more comprehensive understanding of the factors that shape the integration process is lacking. This study aimed at addressing this gap by analysing the integration process of national CBHW programmes in health systems in LMICs, with a special emphasis on Zambia.

Methodology: This was a qualitative study that used case study and systematic review study designs. The case study focused on Zambia and analysed the integration processes of Community Health Assistants (CHAs) into the health system at district level (Papers I-III). Data collected using key informant interviews, participant observation, in-depth interviews and focus group discussions were analysed using thematic analysis. The systematic review analysed, using thematic and pathways analysis, the integration process of national CBHWs into health systems in LMICs (Brazil, Ethiopia, India and Pakistan)-(Paper IV). The framework on the integration of health innovations into health systems guided the overall analysis.

Results: Factors that facilitated the integration of CHAs into the health system in Zambia included the HRH crisis which triggered the willingness by the Ministry of Health to develop and support implementation of the integration strategy-the CHA strategy. In addition, the attributes of the CHA strategy, such as the perceived competence of CHAs compared to other CBHWs, enhanced the community’s confidence in the CHA services. Involvement of the community in selecting CHAs also increased the community’s sense of programme ownership. However, health system characteristics such as limited support by some support staff, supply shortages as well as limited integration of CHAs into the district governance system affected CHAs’ ability to deliver services. In other LMICs, as in Zambia, the HRH problems necessitated the development of integration strategies. In addition, the perceived relative advantage of national CBHWs with regard to delivering health services compared to the other CBHWs also facilitated the integration process. Furthermore, the involvement of community members and some politicians in programme processes enhanced the perceived legitimacy, credibility and relevance of programmes in other LMICs. Finally, the integration process within the existing health systems enhanced programme compatibility with health system elements such as financing. However, a rapid scale-up process, resistance from other health workers, ineffective incentive structures, and discrimination of CBHWs based on social, gender and economic status inhibited the integration process of national CBHWs into the health systems.

Conclusion: Strengthening the integration process requires fully integrating the programme into the district health governance system; being aware of the factors that can influence the integration process such as incentives, supplies and communication systems; clear definition of tasks and work relationships; and adopting a stepwise approach to integration process.

Place, publisher, year, edition, pages
Umeå: Umeå University, 2015. 82 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1706
Keyword
Human resources for health, National community-based health workers, Health Innovations, Integration, Health Systems, Low and middle income countries, Zambia.
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
urn:nbn:se:umu:diva-101807 (URN)978-91-7601-240-6 (ISBN)
Public defence
2015-05-08, Room 135, Family Medicine, Norrlands University Hospital, Umeå University, 901 87, 13:00 (English)
Opponent
Supervisors
Available from: 2015-04-17 Created: 2015-04-13 Last updated: 2015-04-29Bibliographically approved

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