ZAMBIA’S COMMUNITY HEALTH ASSISTANT PROGRAM

By: Katharine Shelley and Yekoyesew Worku

Case Studies of Large-Scale Community Health Worker Programs was derived from the Developing and Strengthening Community Health Worker Programs at Scale: A Reference Guide and Case Studies for Program Managers and Policymakers, edited by Henry Perry, Lauren Crigler, and Steve Hodgins.

Originally published in May 2014 by USAID’s flagship Maternal and Child Health Integrated Program (MCHIP), it was created in response to the rapid increase in and expansion of CHW programs in low- and middle-income countries over the past decade. In January 2017, a companion document was prepared to provide guidance on 13 case studies, including Afghanistan, Bangladesh, Brazil, Ethiopia, Niger, India, Indonesia, Iran, Nepal, Pakistan, Rwanda, Zambia, and Zimbabwe. CHW Central is serializing the case studies over time.

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Summary

Background

The community Health Assistant (HA) Program is an emerging national initiative to bring PHC as close to the home as possible. The first community HAs were trained during 2011–12 and deployed in late 2012. The Government of the Republic of Zambia (GRZ) aims to scale the program nationally to over 5,000 community HAs using a phased approach.¹

 

Summary

Background

The community Health Assistant (HA) Program is an emerging national initiative to bring PHC as close to the home as possible. The first community HAs were trained during 2011–12 and deployed in late 2012. The Government of the Republic of Zambia (GRZ) aims to scale the program nationally to over 5,000 community HAs using a phased approach.¹

Implementation

Community HAs are expected to split their time between the health post (20%) and community (80%) for household visits, community education, and health promotion activities.

Training

Community HAs attend one year of formalized pre-service training on prevention, health promotion, and curative care. The 12 training modules include theoretical and practical training components. The tutors at the community HA training school consist of well-experienced health professionals.

Roles/responsibilities

The main responsibilities of the community HAs are health promotion and disease prevention. Community HAs are also trained in basic curative services that they can provide at the health post and in the community. In addition, they are responsible for identifying patients who are in need of referral to the next level in the health system, usually a health center.

Incentives

Community HAs receive a salary of 2,600 ZMK per month (US$465) and other civil servant benefits. They are also provided with a bicycle, mobile phone, shoes, an umbrella, a backpack, and a uniform—all of which are GRZ property.

Supervision

About half of community HAs are supervised by the in-charge at the nearest rural health center. The remainder of the community HAs work from a health post where one or more additional highly trained staff members are posted. In this case, one of these staff members is designated as the community HA supervisor. Supervision is designed to be conducted at the health post and in the community level on a monthly basis using standardized supervisory checklists.

Impact

Since this is a new program that began only in 2011, there is no evidence yet of impact. An initial independent assessment will be carried out in late 2014.

What is the historical context of Zambia’s Community Health Assistant Program?

Zambia is a landlocked country in Southern Africa with a predominantly rurally based population of 14 million.² The majority (81%) of Zambia’s facilities are within the public sector. Zambia is faced with a severe HRH crisis due to an overall shortage in the number of health care workers (0.93 clinical staff per 1,000 people), an urban/rural misdistribution of the workforce, and an imbalanced skills mix.^3,4 Beginning with the 2006–2010 Zambia National Health Strategic Plan, the HRH crisis was officially recognized as an MOH priority.⁵ Zambia estimated it has less than half as many health care workers as are necessary to deliver basic health care services to the population.⁵ Over 60% of Zambians live in rural areas,⁶ where access to health care is a challenge, in part due to the distances between populations and providers. It is estimated that only half of the rural population lives within five kilometers of a health facility.⁷ HRH challenges are exacerbated by the large burden of HIV, malaria, and TB in the population.⁸ The serious HRH shortage also makes staffing difficult: an estimated 40% of positions in rural health centers remain vacant.⁸

In light of these HRH challenges, the National Community Health Worker strategy was launched by MOH in 2010.¹ A central aim of the strategy was to formalize the role of a nationally supported community health workforce, called community health assistants (HAs). The key difference between community HAs and existing CHVs is in the length of training (community HAs undergo one year of standardized training), standard remuneration (community HAs are put on the government payroll), regulation (community HAs are registered through a regulatory body), and incorporation into the Zambian health system (community HAs receive drugs from the supervisory health center).⁸ Community HAs are supervised by nurses and are expected to relieve nurses from some of their heavy workload through task-sharing.

Zambia framed much of its community HA program around the experience of the HEW cadre in Ethiopia. An in-depth analysis of the development of the community HA strategy, which outlines the policy development process, has recently been conducted.⁸

In addition to community HAs, there are an estimated 23,500 CHVs in Zambia.⁹ The volunteer network is primarily managed by implementing partners, mostly NGOs. Results from an assessment of the CHV program will be available in mid-2014.

What are Zambia’s health needs?

Similar to many other Southern African countries, communicable diseases (HIV/AIDS, TB, malaria) contribute greatly to the overall disease burden in Zambia. Zambia has the 7th highest prevalence of HIV infection in the world, with 12.5% of the population (approximately 1 million people) living with HIV/AIDS.10 Zambia has among the highest incidences of TB and malaria in the world.^11,12 In addition to the communicable disease burden, in the last decade an increase in the prevalence of NCDs has been observed.¹³ During 2008, the top five reasons for visitations to a health facility included: malaria, respiratory infection, diarrhea, trauma, and skin infections.³

Zambia is also faced with severe maternal, neonatal, and child health challenges, although the most recent 2007 DHS showed progress in these areas. Since the 2002 DHS survey, the MMR has been reduced from 729 to 591 deaths per 100,000 live births; the IMR has been reduced

from 95 to 70 deaths per 1,000 live births; and under-5 mortality has been reduced from 168 to 119 deaths per 1,000 live births.³ However, Zambia is not expected to reach the health targets for MDG 4 (Reduce Child Mortality) or MDG 5 (Improve Maternal Health) by 2015.¹⁴

What is the existing health infrastructure?

During the 1980s, health sector reform led to the establishment of semi-autonomous hospital management within hospitals in Zambia.⁷ This was followed by further decentralization in the early 1990s, leading to the creation of District Health Boards with increased responsibility for decision-making at the district level.^7,15 In 1995 the National Health Service Act established the Central Board of Health to govern “the executive functions of service provision: commissioning health services in the health sector, performance support, monitoring and evaluation, national human resource development, and national health facilities planning,” while the actual management of service delivery was carried out by the District Health Boards.¹⁵ After the dissolution of the Central Board of Health in the mid-2000s, the MOH reassumed full authority. In 2013, the Zambian health system underwent another reorganization with the creation of a separate Ministry for Community Development, Mother and Child Health (MCDMCH). The MOH is still responsible for all aspects of training the health workforce; however, the operations of the community HA at the community level now fall within the purview of MCDMCH, and specifically under the direction of their district-level counterparts.

The Zambian health system is structured into six tiers: (1) Outreach Services; (2) Health Posts (307 altogether); (3) Health Centers (1,131 rural and 409 urban altogether); (4) First-level

District Hospitals (84 altogether); (5) Second-level Provincial Hospitals (19 altogether); and (6) Third-level Referral Hospitals (6 altogether).⁵ Of the 1,956 health facilities in Zambia, 81% are government owned, 13% are private, and 6% are faith-based.⁴

What type of program has been implemented?

Community HAs are formally recognized as a cadre by the MOH and MCDMCH. Over the next 5 years, significant government and donor support is committed for the scale-up of the community HA program.¹⁶ Community HAs can work side by side and in collaboration with other formally trained health staff at the health posts (who are typically nurses and environmental health technologists) and with community development assistants as well as social welfare volunteers at the community level who work on issues related to gender, environmental health, education, personal finance, and home economics. Community HAs also play a role in coordinating with the CHVs to create monthly work plans. One-half of the graduates of the initial pilot class of the community HA training program are stationed side by side with other, more qualified health care workers—this is the ideal scenario in that community HAs can refer patients from the community to the nurse at the health post. A formalized referral process exists, and community HAs maintain a referral log. In many cases, task-shifting from health care workers to the community HAs relieves time pressures, so much so that the health care staff who are based at health posts have requested that community HAs work at the health post (rather than in the community) more than two days per week.¹⁷

Following one year of training with a curriculum designed to match Zambia’s disease burden, the community HAs deploy to their home communities to begin working. Community HAs are required to conduct a basic assessment of their communities before engaging in service provision. This includes a community diagnosis (baseline health status of the community through available primary or secondary data sources) and mapping of the catchment area and resources. These initial activities help community HAs determine the priority health-related issues and support the development of a community action plan. Following action planning, community HAs begin service provision both at the health post and at the community/household level with guidance to spend 20% of their time at the health post, for basic curative and referral

services, and the remaining 80% for house-to-house visits (during which they can perform basic curative and referral services) and community educational health talks about disease prevention and control.

The scope of work for community HAs covers a broad array of services within disease control and prevention and family health packages. The key tasks of the community HAs are listed in Table 1 by programmatic area. Community HAs are instructed to refer patients with severe illness or with diseases outside their scope of training to the nearest health center.

Table 1. Key tasks within the community health assistant’s scope of work

What about the community’s role?

The Neighborhood Health Committee (NHC) plays an active role as part of the recruiting panel, alongside the District Community Medical Officer (DCMO) and a representative from the supervising health facility. The NHC assists with recruiting and selecting the community HA as well as liaising with the community HA and CHVs. CHVs often accompany the community HA to assist with household visits. CHVs also sensitize the community, assist community-based malaria agents with the diagnosis and treatment of malaria at the community level, and assist community-based distributors of FP by providing counseling.

How does Zambia select, train, and retain its Community Health Assistants?

The MOH alerts provinces and the MCDMCH alerts respective DCMOs about how many recruits to send from their district to the community HA training school. The DCMO works with the NHCs to distribute recruitment flyers in catchment areas that need community HAs. Each recruit is screened by a panel of NHC members, health center staff, and a DCMO representative—and this panel is responsible for making the final selection of community HA candidates. Recruitment preference is given to women who meet the criteria listed below, particularly if they have previously served as a CHV. In the first and second classes of community HAs recruited in 2011 and 2012, approximately half of the trainees were female.

Community HA recruits must meet the following criteria in order to be selected for training:¹

Have completed Minimum Grade 12 and 2 “O” levels (one should be in English)
Be 18–38 years of age
Be a Zambian citizen, living in the recruitment catchment area for at least 6 months
Be endorsed by the NHC
Have passed a personal interview with a panel of NHC members, health center staff, and a member of the District Community Medical Office
Have previous experience with community health work

Community HA recruits attend one year of formal pre-service training at one of two training schools in the country. A team of 10 tutors teach the community HA recruits in rotating modules with both theoretical and practical components. The practical component involves rotating recruits to local clinics near the training schools. The training modules focus on prevention, promotion, and basic curative care. The curriculum covers the following topical areas: (1) behavioral health sciences; (2) disease prevention and control and PHC; (3) environmental health; (4) reproductive health; (5) child health; (6) medical/surgical conditions;

(7) provision of health care at the health post and in the community (including basic diagnostic procedures and provision of a small number of drugs).

The initial pilot class of community HAs also attended a 2-week in-service training for additional skills that had been added later to the community HA scope of work. The skills included, for instance, injecting medication and attending emergency deliveries. Construction of a second community HA training school began in July 2013; upon completion, it will provide the ability to train an additional 208 community HAs per year. Enrollment of the first class is expected in early 2014, thereby increasing Zambia’s total community HA training capacity to roughly 500 students per year.

The key retention strategy is recruiting community HAs from their home communities, to which they will return following their training, so they will not have a desire to move elsewhere.

How does Zambia supervise its Community Health Assistants?

Community HA supervisors and district community HA coordinators attend a five-day training at the provincial level for orientation on the community HA program and their key supervisory duties. Supervisors are equipped with a supervision manual and monthly supervision tools to facilitate routine supervision. Each community HA is supervised by the in-charge at the nearest “parent” health facility. In facilities where community HAs work alongside additional qualified staff, the supervisor is located on-site. Otherwise, the supervisor generally comes from the nearest health center. Supervision is designed to be conducted at the health post and in the community. In practice, supervision out in the community rarely happens due to competing needs of the supervisor. The official supervisory visit is intended to occur on a monthly basis.

How is the Community Health Assistant Program financed?

Financing to date for the community HA program has been through a multi-stakeholder collaborative process. The British Department for International Development supported the planning and development, pilot implementation, and M&E, and intends to support scale-up through 2018. USAID financed the Zambia Integrated Systems Strengthening Program to provide initial support for training of community HA supervisors and for the salaries of community HA trainers. UNICEF provided support for some of the community HA training materials. The GRZ also contributes financially by supporting recurrent costs to run the community HA training school, and it now covers the cost for the community HA trainers. In July 2013, the MCDMCH took over financial responsibility for paying community HA salaries.

What are the program’s demonstrated impact and continuing challenges?

Results from two impact evaluations are expected later in 2014. Boston University and its local in-country representative partner, the Zambia Center for Applied Health Research and Development, are conducting an evaluation of the impact of community HAs on community access to health care as measured by proportion of children who receive treatment for malaria, pneumonia, and diarrhea. The Clinton Health Access Initiative (CHAI) is conducting a task- shifting study to assess how the introduction of community HAs affects the types and volumes of patients seeking care at the health post and supervising health center. Results from both studies are expected to help inform GRZ policy and decision-making about the community HA program going forward.

In addition to impact evaluations, there is an M&E component of the National Community Health Assistant Program, with specific indicators and registers developed by the MOH and partners for tracking community-level health. A relatively new data reporting system, called District Health Information System Version 2.0 (DHIS2), was incorporated into the program; community HAs are trained on the tools and procedures for utilizing the DHIS2 mobile health reporting platform. Each health post with community HAs received a mobile phone plus copies of registers to support monthly data summarization and reporting. Community HAs are responsible for submitting monthly aggregated data via paper reports to their supervisors and via mobile reports to the national level. At present, mobile data reported by community HAs are not being routinely analyzed, but discussions were under way on how best to utilize the data and how to ensure the data were received at the district level as well as nationally. In the future, this mobile data reporting system may provide key information on the impact of community HAs and their contribution to Zambia’s health services.

Finally, a qualitative process evaluation of the rollout of the community HA program was conducted in 2012–13. The evaluation identified several challenges, including (1) lack of regular supervision visits, partially due to transportation challenges; (2) delays in salary payments; (3) inadequate drug supply stocks and/or unwillingness of facility staff to release drugs for community- and household-level use; (4) large catchment areas (more than the originally estimated catchment size of 3,500 persons) and long travel time between villages; (5) communication challenges between the national and district levels; and (6) lack of a clear role differentiation between community HAs and CHVs.¹⁷

References

1. MOH Zambia. National Community Health Worker Strategy in Zambia. Lusaka, Zambia; 2010.
2. CIA. World Factbook: Zambia. 2013. Available at: https://www.cia.gov/library/publications/the-world-factbook/geos/za.html. Accessed December 12, 2013.
3. MOH Zambia. Republic of Zambia: National Health Strategic Plan 2011-2015. Lusaka, Zambia; 2011. Available at: http://www.internationalhealthpartnership.net/fileadmin/uploads/ihp/Documents/Country_P ages/Zambia/ZambiaNHSP2011to2015final.pdf.
4. MOH Zambia. The 2012 List of Health Facilities in Zambia: Preliminary Report, v15. Lusaka, Zambia; 2013.
5. Ferrinho P, Siziya S, Goma F, Dussault G. The human resource for health situation in Zambia: deficit and maldistribution. Hum Resour Health 2011; 9(1): 30. doi:10.1186/1478- 4491-9-30.
6. Index Mundi. Zambia Demographics Profile 2013. 2013. Available at: http://www.indexmundi.com/zambia/demographics_profile.html. Accessed November 11, 2013.
7. Chankova S, Sulzbach S. Zambia Health Services and Systems Program. Occasional Paper Series. Human Resources for Health, Number I. Bethesda, MD: Health Services and Systems Program, Abt Associates Inc.; 2006. Available at: http://www.abtassociates.com/reports/hssp_hrsynthesis1.pdf.
8. Zulu JM, Kinsman J, Michelo C, Hurtig A-K. Developing the national community health assistant strategy in Zambia: a policy analysis. Health Res Policy Syst 2013; 11(1): 24. doi:10.1186/1478-4505-11-24.
9. MOH Zambia. Zambia’s National Community Health Worker Strategy. In: Second Global Forum on Human Resources for Health. Bangkok, Thailand; 2011. Available at: http://www.who.int/workforcealliance/forum/2011/hrhawardscs29/en/. Accessed October 18, 2013.
10. Kaiser Family Foundation. Adult HIV/AIDS Prevalence Percent (Age 15-49). 2013. Available at: http://kff.org/global-indicator/adult-hivaids-prevalence-percent/. Accessed November 7, 2013.
11. Kaiser Family Foundation. People Living with TB. 2013. Available at: http://kff.org/global- indicator/people-living-with-tb/. Accessed November 7, 2013.
12. Kaiser Family Foundation. Reported Malaria Cases. 2012. Available at: http://kff.org/global- indicator/malaria-cases/. Accessed November 7, 2013.
13. MOH Zambia. Republic of Zambia: National Human Resources for Health Strategic Plan 2011–2015. Lusaka, Zambia; 2011.
14. UNDP. Millennium Development Goals: Progress Report, Zambia, 2013. Lusaka, Zambia; 2013. Available at: http://www.undp.org/content/dam/undp/library/MDG/english/MDG Country Reports/Zambia/MDG Report 2013.pdf.
15. Mutemwa RI. HMIS and decision-making in Zambia: re-thinking information solutions for district health management in decentralized health systems. Health Policy Plan 2006; 21(1): 40-52. doi:10.1093/heapol/czj003.
16. DFID Zambia. DFID Business Case for Human Resources for Health Programme in Zambia. 2012. Available at: projects.dfid.gov.uk/IatiDocument/3736920.docx. Accessed November 10, 2013.
17. Worku Y, Shelley KD, Clinton Health Access Initiative. Community Health Assistant Process Evaluation. Lusaka, Zambia; 2013.

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^s Katharine Shelley, a student at the Johns Hopkins Bloomberg School of Public Health, and Yekoyesew Worku, Human Resources for Health Technical Advisor for the Clinton Health Access Initiative/Zambia are the authors of this case study.