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Innovation in health service delivery: integrating community health assistants into the health system at district level 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: 0000-0001-7087-1467
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.
2015 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 15, 38- p.Article in journal (Refereed) Published
Abstract [en]

Background: To address the huge human resources for health gap in Zambia, the Ministry of Health launched the National Community Health Assistant Strategy in 2010. The strategy aims to integrate community-based health workers into the health system by creating a new group of workers, called community health assistants (CHAs). However, literature suggests that the integration process of national community-based health worker programmes into health systems has not been optimal. Conceptually informed by the diffusion of innovations theory, this paper qualitatively aimed to explore the factors that shaped the acceptability and adoption of CHAs into the health system at district level in Zambia during the pilot phase. Methods: Data gathered through review of documents, 6 focus group discussions with community leaders, and 12 key informant interviews with CHA trainers, supervisors and members of the District Health Management Team were analysed using thematic analysis. Results: The perceived relative advantage of CHAs over existing community-based health workers in terms of their quality of training and scope of responsibilities, and the perceived compatibility of CHAs with existing groups of health workers and community healthcare expectations positively facilitated the integration process. However, limited integration of CHAs in the district health governance system hindered effective programme trialability, simplicity and observability at district level. Specific challenges at this level included a limited information flow and sense of programme ownership, and insufficient documentation of outcomes. The district also had difficulties in responding to emergent challenges such as delayed or non-payment of CHA incentives, as well as inadequate supervision and involvement of CHAs in the health posts where they are supposed to be working. Furthermore, failure of the health system to secure regular drug supplies affected health service delivery and acceptability of CHA services at community level. Conclusion: The study has demonstrated that implementation of policy guidelines for integrating community-based health workers in the health system may not automatically guarantee successful integration at the local or district level, at least at the start of the process. The study reiterates the need for fully integrating such innovations into the district health governance system if they are to be effective.

Place, publisher, year, edition, pages
BioMed Central, 2015. Vol. 15, 38- p.
Keyword [en]
integration, health innovations, community-based health workers, health system
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-100290DOI: 10.1186/s12913-015-0696-4ISI: 000348820200001OAI: oai:DiVA.org:umu-100290DiVA: diva2:793187
Available from: 2015-03-06 Created: 2015-02-27 Last updated: 2017-12-04Bibliographically 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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