Innovation in health service delivery: integrating community health assistants into the health system at district level in Zambia

BMC Health Services Research

Charles Michelo¹  John Kinsman²  Anna-Karin Hurtig²  Joseph Mumba Zulu² 

[1] Department of Public Health, School of Medicine, University of Zambia, Lusaka, Zambia;Umeå International School of Public Health (UISPH), Umeå University, Umeå SE 90185, Sweden

关键词: Health system;    Community-based health workers;    Health innovations;    Integration;   

Others  :  1109797
DOI  :  10.1186/s12913-015-0696-4

 received in 2014-04-17, accepted in 2015-01-12,  发布年份 2015

【 摘 要 】

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.

【 授权许可】

   
2015 Zulu et al.; licensee BioMed Central.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Atun R: Health systems, systems thinking and innovation. Health policy and planning 2012, 27(suppl 4):iv4-iv8.
• [2]Cutler DM, McClellan M: Is technological change in medicine worth it? Health Aff 2001, 20(5):11-29.
• [3]Bhutta ZA, Chopra M, Axelson H, Berman P, Boerma T, Bryce J, et al.: Countdown to 2015 decade report (2000–10): taking stock of maternal, newborn, and child survival. Lancet 2010, 375(9730):2032-44.
• [4]Negusse H, McAuliffe E, MacLachlan M: Initial community perspectives on the health service extension programme in welkait, Ethiopia. Hum Resour Health 2007, 5(1):21. BioMed Central Full Text
• [5]Celletti F, Wright A, Palen J, Frehywot S, Markus A, Greenberg A, et al.: Can the deployment of community health workers for the delivery of HIV services represent an effective and sustainable response to health workforce shortages? Results of a multicountry study. Aids 2010, 24:S45-57.
• [6]Zulu JM, Kinsman J, Michelo C, Hurtig A-K: Integrating national community-based health worker programmes into health systems: a systematic review identifying lessons learned from low-and middle-income countries. BMC Public Health 2014, 14(1):987. BioMed Central Full Text
• [7]Liu A, Sullivan S, Khan M, Sachs S, Singh P: Community health workers in global health: scale and scalability. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine 2011, 78(3):419-35.
• [8]Bhutta ZA, Lassi ZS, Pariyo G, Huicho L: Global experience of community health workers for delivery of health related millennium development goals: a systematic review, country case studies, and recommendations for integration into national health systems. Global Health Workforce Alliance 2010.
• [9]Douthwaite M, Ward P: Increasing contraceptive use in rural Pakistan: an evaluation of the lady health worker programme. Health policy and planning 2005, 20(2):117-23.
• [10]Balabanova D, McKee M, Mills A: Good health at low cost 25 years on. What makes a successful health system? In. London United Kingdom London School of Hygiene and Tropical Medicine 2011; 2011.
• [11]Atun R, de Jongh T, Secci F, Ohiri K, Adeyi O: A systematic review of the evidence on integration of targeted health interventions into health systems. Health policy and planning 2010, 25(1):1-14.
• [12]Admassie A, Abebaw D, Woldemichael AD: Impact evaluation of the Ethiopian health services extension programme. Journal of Development Effectiveness 2009, 1(4):430-49.
• [13]Amare Y: Non-financial incentives for voluntary community health workers: a qualitative study. In. Addis Ababa Ethiopia JSI Research and Training Institute Last Ten Kilometers Project [L10K] 2009.; 2009.
• [14]Glenton C, Colvin CJ, Carlsen B, Swartz A, Lewin S, Noyes J, Rashidian A: Barriers and facilitators to the implementation of lay health worker programmes to improve access to maternal and child health: qualitative evidence synthesis. Cochrane Database Syst Rev 2013, 10.
• [15]Zulu JM, Kinsman J, Michelo C, Hurtig A-K: Hope and despair: community health assistants’ experiences of working in a rural district in Zambia. Hum Resour Health 2014, 12(1):30. BioMed Central Full Text
• [16]Crigler L, Furth R: Improving CHW program functionality performance and engagement: operations research results from Zambia. In. [Bethesda Maryland] University Research Company [URC] Health Care Improvement Project [HCI] 2012 Jun.
• [17]Zulu JM, Kinsman J, Michelo C, Hurtig A-K: Developing the national community health assistant strategy in Zambia: a policy analysis. Health Research Policy and Systems 2013, 11(1):24. BioMed Central Full Text
• [18]Callaghan M, Ford N, Schneider H: Review A systematic review of task-shifting for HIV treatment and care in Africa. Hum Resour Health 2010, 8:8-16. BioMed Central Full Text
• [19]Gilmore B, McAuliffe E: Effectiveness of community health workers delivering preventive interventions for maternal and child health in low-and middle-income countries: a systematic review. BMC Public Health 2013, 13(1):1-14. BioMed Central Full Text
• [20]Ashraf N, Natalie K: Community health workers in Zambia: incentive design and management. Harvard Business School Case 2010:910–030.
• [21]Gilson L e: Health Policy and Systems Research: A Methodology Reader. In. Geneva: Alliance for Health Policy and Systems Research. World Health; 2012.
• [22]Van Olmen J, Criel B, Van Damme W, Marchal B, Van Belle S, Van Dormael M, et al.: Analysing health systems to make them stronger: ITGPress. 2010.
• [23]Zulu JM, Michelo C, Msoni C, Hurtig A-K, Byskov J, Blystad A: Increased fairness in priority setting processes within the health sector: the case of Kapiri-Mposhi District, Zambia. BMC Health Serv Res 2014, 14(1):75. BioMed Central Full Text
• [24]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. BioMed Central Full Text
• [25]Mutale W, Mwanamwenge MT, Balabanova D, Spicer N, Ayles H: Measuring governance at health facility level: developing and validation of simple governance tool in Zambia. BMC international health and human rights 2013, 13(1):1-9. BioMed Central Full Text
• [26]Bocoum FY, Kouanda S, Kouyaté B, Hounton S, Adam T: Exploring the effects of task shifting for HIV through a systems thinking lens: the case of Burkina Faso. BMC Public Health 2013, 13(1):997. BioMed Central Full Text
• [27]Fishbein M: A theory of reasoned action: Some applications and implications. In.: University of Nebraska Press; 1979.
• [28]Rogers EM: Diffusion of innovations. In.: New York [etc.]: Free Press; 1995.
• [29]Scott SD, Plotnikoff RC, Karunamuni N, Bize R, Rodgers W: Factors influencing the adoption of an innovation: An examination of the uptake of the Canadian Heart Health Kit (HHK). Implement Sci 2008, 3(1):41. BioMed Central Full Text
• [30]Rogers EM: A prospective and retrospective look at the diffusion model. J Health Commun 2004, 9(S1):13-19.
• [31]Nanyonjo A, Nakirunda M, Makumbi F, Tomson G, Källander K: Community acceptability and adoption of integrated community case management in Uganda. AmJTrop Med Hyg 2012, 87(5 Suppl):97-104.
• [32]Braun V, Clarke V: Using thematic analysis in psychology. Qual Res Psychol 2006, 3(2):77-101.
• [33]Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O: Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q 2004, 82(4):581-629.
• [34]Belete A SK, Vosburg KB, Mulenda L, Musonda M, Chizema E, Phiri C: Lessons learnt from the pilot class of community health assistants in Zambia. A process evaluation to inform national scale up of the CHA program Ministry of Health. In. Lusaka Ministry of Community Development Mother and Child Health and Clinton Health Access Initiative; 2014.
• [35]Van Damme W, Kober K, Kegels G: Scaling-up antiretroviral treatment in Southern African countries with human resource shortage: how will health systems adapt? Soc Sci Med 2008, 66(10):2108-21.
• [36]Assefa Y, Van Damme W, Hermann K: Human resource aspects of antiretroviral treatment delivery models: current practices and recommendations. Curr Opin HIV AIDS 2010, 5(1):78-82.
• [37]Prasad BM, Muraleedharan VR: Community health workers: a review of concepts, practice and policy concerns. A review as part of ongoing research of International Consortium for Research on Equitable Health Systems (CREHS) 2007.
• [38]Afsar HA, Younus M: Recommendations to strengthen the role of lady health workers in the national program for family planning and primary health care in Pakistan: the health worker’s perspective. J Ayub Med Coll Abbottabad 2005, 17.
• [39]Lehmann U, Sanders D: Community Health Workers: What do we know about them? Organización Mundial de la Salud, Ginebra 2007:21–22.
• [40]Atun R, Ohiri K, Adeyi O: Integration of Health Systems and Priority Health, Nutrition, and Population Interventions: A Framework for Analysis and Policy Choices. Ins: World Bank, Washington, DC; 2008.
• [41]Schneider H, Hlophe H, van Rensburg D: Community health workers and the response to HIV/AIDS in South Africa: tensions and prospects. Health policy and Planning 2008, 23(3):179-87.
• [42]Jaskiewicz W, Tulenko K: Increasing community health worker productivity and effectiveness: a review of the influence of the work environment. Hum Resour Health 2012, 10(1):38. BioMed Central Full Text
• [43]Sterman JD: System dynamics modeling. Calif Manag Rev 2001, 43(4):8-25.
• [44]Edvardsson K, Ivarsson A, Eurenius E, Garvare R, Nyström ME, Small R, et al.: Giving offspring a healthy start: parents’ experiences of health promotion and lifestyle change during pregnancy and early parenthood. BMC Public Health 2011, 11(1):936. BioMed Central Full Text
• [45]Graneheim UH, Lundman B: Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 2004, 24(2):105-12.
• [46]Hsieh H-F, Shannon SE: Three approaches to qualitative content analysis. Qual Health Res 2005, 15(9):1277-88.
• [47]Lincoln YS: Naturalistic inquiry, vol. 75: Sage; 1985.
• [48]Patton MQ: Enhancing the quality and credibility of qualitative analysis. Health Serv Res 1999, 34(5 Pt 2):1189.