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

Below is the citation and abstract of a new paper in the open-access journal BMC Health Services Research. Underneath I have added some illustrative quotes from participants in the research. This is a crucial subject and I have invited the authors to join us and explore further on HIFA-Zambia.

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

by Joseph Mumba Zulu, Anna-Karin Hurtig, John Kinsman et al.

BMC Health Services Research 2015, 15:38 (28 January 2015)


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.


“The most important thing to remember is that unlike the training for the other community health workers, the CHA’s training is longer…. It runs for 1 year.” (Neighbourhood health committee FGD 1, female participant 2).

“We have two CHAs who were trained. But to our surprise, they are not allowed to give medicines. They just watch support staff give medicines.” (Neighbourhood health committee FGD 2, male participant 1).

“But the complaint in the community is that CHAs are unable to treat some illnesses like malaria as they do not have drug kits.” (Neighbourhood health committee FGD 5, male participant 1).

“Sometimes CHAs come and ask for antibiotics to use. But am a little sceptical giving them drugs to administer because I don’t know the extent of their training.” (CHA supervisor 2, male).

“We are still waiting for monitors to come from the national level so that we can share with them some of challenges that we are experiencing in supervising CHAs.” CHA supervisor 4, female).

“We have been told that CHAs are under the Ministry of Health, but unlike other health workers, they are also controlled by the other groups. We are therefore not sure if they are totally under the Ministry of Health.” (CHA supervisor 3, female).

Best wishes, Neil

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Mobile health in Sierra Leone: Evidence and implications for health systems

mHealth in Sierra Leone

Sierra Leone has taken important steps over the last decade towards improving the health status of its people; the launch of the Free Healthcare Initiative (FHCI) in 2010 was a major milestone that made healthcare services available free of charge for pregnant and lactating women and children under five years. But the current maternal and newborn health statistics illustrate that the health system still faces challenges.

There is a need to increase demand, improve healthcare provision, and facilitate the connection between communities and healthcare providers.

These challenges and the need for stronger involvement of communities and better communication between these and health workers came even more to the forefront during the current Ebola crisis.

Mobile communication technologies are rapidly spreading globally and Africa is no exception.

It is an opportune time to use this technology development as a platform for public health interventions. But the evidence for how best to use mobile communication technology for health (called mobile health, abbreviated as mHealth) is still sparse.

This technical brief summarises a mobile health intervention research in Bombali district, in north-west Sierra Leone. It describes how health providers were connected to clients through mobile telephones (the interventions), and the assessment of these interventions (the findings regarding results and impact). This technical brief provides recommendations for healthcare providers and policy-makers interested in adopting mobile health interventions to advance maternal and newborn health.

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