An exploration of facilitators and challenges in the scale-up of a national, public sector community health worker cadre in Zambia: a qualitative study.

BACKGROUND: In 2010 a public sector cadre of community health workers called Community Health Assistants (CHAs) was created in Zambia through the National Community Health Worker Strategy to expand access to health services. This cadre continues to be scaled up to meet the growing demands of Zambia's rural population. We summarize factors that have facilitated the scale-up of the CHA program into a nationwide CHW cadre and the challenges of introducing and institutionalizing the cadre within the Zambian health system. METHODS: Semi-structured, individual interviews were held across 5 districts with 16 CHAs and 6 CHA supervisors, and 10 focus group discussions were held with 93 community members. Audio recordings of interviews and focus group discussions were transcribed and thematically coded using Dedoose web-based software. RESULTS: The study showed that the CHAs play a critical role in providing a wide range of services at the community level, as described by supervisors and community members. Some challenges still remain, that may inhibit the CHAs ability to provide health services effectively. In particular, the respondents highlighted infrequent supervision, lack of medical and non-medical supplies for outreach services, and challenges with the mobile data reporting system. CONCLUSIONS: The study shows that in order to optimize the impact of CHAs or other community health workers, key health-system support structures need to be functioning effectively, such as supervision, community surveillance systems, supplies, and reporting. The Ministry of Health with support from partners are currently addressing these challenges through nationwide supervisor and community data trainings, as well as advocating for adding primary health care as a specific focus area in the new National Health Strategy Plan 2017-2021. This study contributes to the evidence base on the introduction of formalized community health worker cadres in developing countries.

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.