Task-shifting impact of introducing a pilot community health worker cadre into Zambia's public sector health workforce.

BACKGROUND: The Zambia Ministry of Health (MOH) recruited and trained a new cadre of Community Health Assistants (CHAs) as part of its National Community Health Strategy. The inaugural class of 307 CHAs completed one year of training in July 2012 and deployed to their communities. METHODS: The impact of the CHA program on the volume and type of health services provided at health posts and their respective referral health centers was measured with a non-randomized difference-in-differences design. Monthly health service provision data was collected for 12 months before and after CHA deployment at 8 health posts along with 8 referral health centers. The analysis controlled for seasonality, changes in non-CHA staffing, and periodic regional child health campaigns, and used facility-level fixed effects. RESULTS: Deploying two CHAs to a health post did not lead to a statistically-discernible increase in services at the intervention facilities. Health services provided at referral health centers increased by 697.9 services per month (95% CI: 131.4 to 1,264.3, p = .016), and combined services (at health posts and referral health centers) increased by 848.6 services per month (95% CI: 178.2 to 1,519.1, p = .013). CONCLUSION: In this pilot, the addition of CHAs in rural areas increased health service provision at referral health facilities and at facilities overall, shifting the burden of basic health services away from more highly trained health workers. Shifting tasks to lesser-trained, less-expensive cadres like the CHAs, policymakers can rapidly improve access to care with constrained budgets. Evaluations measuring the direct impact of lower level cadres without accounting for task-shifting may underestimate their contribution to the health workforce.

Improving Allocation And Management Of The Health Workforce In Zambia.

Building a health workforce in low-income countries requires a focused investment of time and resources, and ministries of health need tools to create staffing plans and prioritize spending on staff for overburdened health facilities. In Zambia a demand-based workload model was developed to calculate the number of health workers required to meet demands for essential health services and inform a rational and optimized strategy for deploying new public-sector staff members to the country's health facilities. Between 2009 and 2011 Zambia applied this optimized deployment policy, allocating new health workers to areas with the greatest demand for services. The country increased its health worker staffing in districts with fewer than one health worker per 1,000 people by 25.2 percent, adding 949 health workers to facilities that faced severe staffing shortages. At facilities that had had low staffing levels, adding a skilled provider was associated with an additional 103 outpatient consultations per quarter. Policy makers in resource-limited countries should consider using strategic approaches to identifying and deploying a rational distribution of health workers to provide the greatest coverage of health services to their populations.