title: Implementation of the Community Health Assistant (CHA) Cadre in Zambia: A Process Evaluation to Guide Future Scale-Up Decisions.
abstract: Universal health coverage requires an adequate health workforce, including community health workers (CHWs) to reach rural communities. To improve healthcare access in rural areas, in 2010 the Government of Zambia implemented a national CHW strategy that introduced a new cadre of healthcare workers called community health assistants (CHAs). After 1 year of training the pilot class of 307 CHAs deployed in September 2012. This paper presents findings from a process evaluation of the barriers and facilitators of implementation of the CHA pilot, along with how evidence was used to guide ongoing implementation and scale-up decisions. Qualitative inquiry was used to assess implementation during the first 6 months of the program rollout, with 43 in-depth individual and 32 small group interviews across five respondent types: CHAs, supervisors, volunteer CHWs, community members, and district leadership. Potential 'implementation moderators' were explored using deductive coding and thematic analysis of participant perspectives on community acceptance of CHAs, supervision support mechanisms, and coordination with volunteer CHWs, and health system integration of a new cadre. Community acceptance of CHAs was generally high, but coordination between CHAs and existing volunteer CHWs presented some challenges. The supervision support system was found to be inconsistent, limiting assurance of consistent quality care delivered by CHAs. Underlying health system weaknesses regarding drug supply and salary payments furthermore hindered incorporation of a new cadre within the national health system. Recommendations for implementation and future scale based on the process evaluation findings are discussed.
authors.affiliation: Department of International Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe St, Room E8009, Baltimore, MD, 21205, USA. katharine.shelley@jhu.edu.|Clinton Health Access Initiative, Lusaka, Zambia. katharine.shelley@jhu.edu.
authors.forename: Katharine D
authors.initials: KD
authors.lastname: Shelley
authors.affiliation: MDG Acceleration Initiative, UNICEF, Lusaka, Zambia.|Clinton Health Access Initiative, Lusaka, Zambia.
authors.forename: Yekoyesew W
authors.initials: YW
authors.lastname: Belete
authors.affiliation: Clinton Health Access Initiative, Lusaka, Zambia.
authors.forename: Sydney Chauwa
authors.initials: SC
authors.lastname: Phiri
authors.affiliation: Human Resources Administration, Ministry of Foreign Affairs, Lusaka, Zambia.|Mother and Child Health, Ministry of Community Development, Mother and Child Health, Lusaka, Zambia.
authors.forename: Mutinta
authors.initials: M
authors.lastname: Musonda
authors.affiliation: Disease Surveillance, Research and Control, Ministry of Health, Lusaka, Zambia.
authors.forename: Elizabeth Chizema
authors.initials: EC
authors.lastname: Kawesha
authors.affiliation: Human Resources and Administration, Ministry of Health, Lusaka, Zambia.
authors.forename: Evelyn Mutinta
authors.initials: EM
authors.lastname: Muleya
authors.affiliation: Mother and Child Health, Ministry of Community Development, Mother and Child Health, Lusaka, Zambia.
authors.forename: Caroline Phiri
authors.initials: CP
authors.lastname: Chibawe
authors.affiliation: Clinton Health Access Initiative, Lusaka, Zambia.
authors.forename: Jan Willem
authors.initials: JW
authors.lastname: van den Broek
authors.affiliation: Clinton Health Access Initiative, Lusaka, Zambia.
authors.forename: Kathryn Bradford
authors.initials: KB
authors.lastname: Vosburg
mesh_terms: D003150:Community Health Workers; D003657:Decision Making; D005260:Female; D006285:Health Planning; D006302:Health Services Research; D006280:Health Workforce; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D036301:Qualitative Research; D015024:Zambia
keywords: Community health workers; Health systems strengthening; Human resources for health; Qualitative process evaluation; Zambia