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Hope and despair: community health assistants' experiences of working in a rural district in Zambia
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. 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
2014 (English)In: Human Resources for Health, ISSN 1478-4491, E-ISSN 1478-4491, Vol. 12, no 1, 30- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: In 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.

METHODS: A 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.

RESULTS: Personal 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.

CONCLUSIONS: Programmes 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.

Place, publisher, year, edition, pages
BioMed Central, 2014. Vol. 12, no 1, 30- p.
Keyword [en]
Community-based health workers, Work experience, Work motivation, Zambia
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-90540DOI: 10.1186/1478-4491-12-30PubMedID: 24886146OAI: oai:DiVA.org:umu-90540DiVA: diva2:728369
Available from: 2014-06-24 Created: 2014-06-24 Last updated: 2017-12-05Bibliographically 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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