In this section we present both the survey and in-depth interview findings. These findings are grouped according to the broad six themes related to inputs in the systems strengthening framework, community activities and service delivery, enabling environments and advocacy, community networks, linkages, partnerships and coordination, resources, and capacity building, organizational and leadership strengthening and monitoring and evaluation and planning.
Characteristics of the study participants
A total of 2,506 participants were recruited for the study across all the 10 provinces of Zambia. Out of these, majority were females (71.1%) and only 28.9% males. The age ranged from 18 to 90 years (mean age= 37.6 and SD=14.5 as shown in Table 2. About half of the participants (53.3%) were aged between 25-45 years, and 21% were adolescents and young people aged 18-24 years (Table B).
Table 2: Recruitments per province and district
Province
|
District
|
Number Recruited
|
Proportion (%)
|
Central
|
1
|
255
|
10.2
|
Copperbelt
|
2
|
245
|
9.8
|
Eastern
|
3
|
251
|
10.0
|
Luapula
|
4
|
255
|
10.2
|
Lusaka
|
5
|
251
|
10.0
|
Muchinga
|
6
|
253
|
10.1
|
Northern
|
7
|
252
|
10.0
|
Northwestern
|
8
|
246
|
9.8
|
Southern
|
9
|
250
|
10.0
|
Western
|
10
|
248
|
9.9
|
Total Recruited
|
|
2506
|
100%
|
|
|
|
|
Location of Facilities
|
|
|
|
Rural
|
|
2461
|
98.2
|
Peri-urban
|
|
29
|
1.2
|
Urban
|
|
16
|
0.6
|
|
|
|
|
Type of Health Facility
|
|
|
|
With -year CHA implementation
|
|
1522
|
60.7
|
With 2 or more years CHA implementation
|
|
984
|
39.3
|
Community activities and service delivery
The role of CHAs in delivering maternal and child health services
Across all the 10 provinces of Zambia and in districts where the CHAI program was implemented, CHAs were reported as key in providing maternal and child health services. One of the key services highlighted by most of the participants includes provision of health education in the community on maternal and neonatal health (MNH). This included teaching pregnant women on the importance of early prenatal booking, attending antenatal and postnatal services, danger signs in pregnant women, nutrition, and malaria prevention (i.e., sleeping under a Mosquito net). CHAs also played a critical role in educating pregnant women to deliver from the facility and generally the importance of utilizing the services provided by health facilities. Further, CHAs provided education to community members such as men, women, adolescents, and young people on the importance of family planning, and how to protect oneself from contracting HIV as well as going for VCT. This was echoed in the expert below:
“They (CHAs) do teach us yes sometimes that if you are pregnant, you are supposed to be coming for antenatal. They teach a lot of things such as taking care of the body and pregnancy, hygiene, cleaning yourself in armpits and private part, budgeting for the baby before giving birth” (224, FGD Community, Itezhi Tezhi District, Central Province).
The finding from the qualitative interviews were complemented by the findings from the quantitative data. In quantitative data, we found that 92.9% out of 2,506 participants in communities where CHAs had been implementing activities for two (2) or more years reported being more aware of people accessing maternal health services after the deployment of CHAs than in communities with one (1)-year CHA program implementation (88.6%). Furthermore individuals (94.2% out of 2,506 participants) in communities where CHAs had been implementing activities for two (2) or more years reported being more aware of people accessing family planning services after the deployment of CHAs compared to communities with one (1)-year CHA program implementation (83.1%). More individuals (89.4% out of 2,506 participants) in communities where CHAs had been implementing activities for two (2) or more years reported being more aware of people accessing nutrition services after the deployment of CHAs compared to 78.9% reported in communities with one (1)-year of CHA program implementation.
With regard child health services, slightly more participants (98.2% out of 2,506 participants) in communities where CHAs had been implementing activities for two (2) or more years reported being more aware of people taking their children for immunization and vaccination after the deployment of CHAs compared to communities with one (1)-year CHA program implementation (93.3%/ 90.1%). (Figure 14). According to the participants, in communities with the CHA program, the CHAs made follow-ups with parents to ensure that mothers went to the clinic and that those who went for postnatal services were taking proper care of their infants. During these visits mothers were also encouraged to ensure infants received all the required immunizations, as one participant said:
“…when the baby is discharged and the mother from the facility they go there to visit them they make sure that they come for postnatal here at the first six days, if they came they have to continue visiting them even at six weeks they have to visit them to encourage them to come to the facility for those vaccines that we give them if they find one who has not come here” (94, IDI, Female In-Charge, Nakonde District, Northern Province).
In addition to encouraging parents to continue with postnatal services as indicated in the quote above, participants also reported that they were aware that CHAs also provided child health services such conducting under five services, weighing, and measuring the length and height of children, vaccinations, and nutrition programmes.
“Yes, I know the activities that CHAs provide, and these activities include immunization and some components of malnutrition I think that’s all. Ahh he normally does that; he helps on taking the weight of the baby and checks on card to check the nutrition status of the baby. Yes, is the babies weight improving or it's going down.” (110, IDI, EHT, Chadiza District, Eastern Province).
Review of data from the Health Management Information System (HMIS) from 2019 (when the CHAs were deployed) and 2020 showed that the health facilities that had CHAs performed better than those health facilities that had no CHAs. This good performance in 2019 and 2020 in health facilities with CHAs was recorded in postnatal care (PNC), antenatal care (ANC), institutional delivery, children fully immunised as well as deliveries by skilled birth attendants as shown in Figures 1 and 3 below.
Regarding nutritional services, the CHAs went further than providing information to promoting uptake of nutrition services including teaching parents and community members how to cook. Most participants stated that CHAs conducted home visitation to assess the nutritional status of the households, identifying malnourished children and referring those with severely malnourishing conditions to the health facility for management.
“They give us medicine and the children are also given medicine, they also give us instructions on the different types of food to eat so that both the mother and child are fit and maintain strong bodies.’’ (55, FGD, Luwingu District, Northern Province).
In addition to the above roles, the CHAs taught community members on sanitation issues such as make toilets and washing hands.
“When I tell them to clean surroundings, make huts where to cook from and have toilets and hand basins near toilets and they do those things then they are supporting me. They also welcome us in their homes when we educate them about different things. Then they are using mosquito nets to prevent malaria and they have also dug pits” (227, IDI, Female, Kawambwa District, Luapula Province).
Barriers to delivering services
Several barriers were reported to influence the delivery of maternal and child health services by the CHAs. Among then include, inadequate transport, difficult in balancing work schedules at community level, shortage of drugs/ commodities and limited CHA legitimacy. These challenges are further described below.
Inadequate transport
It was reported that the CHAs had still difficulties providing services due to limited transportation. Participants also reported that only a few health facilities that had been supported by the government implementing partners such as CHAI had been provided with bicycles to use to provide services to the communities. Thus, the CHAs walked long distances to provide health services and in some cases, this affected the number of households they visited in a day. Many CHAs requested the need to having transportation for them to adequately provide services as per the quote below:
“The ones that are being supported by CHAI were given bicycles. Each facility, each health post was given a bicycle so those CHAs can use bicycles. Of course, they're not enough. The ideal situation is maybe for us to have for each CHA, a bicycle a mode of transport, ---, but each facility has at least one bicycle and one motorbike compared to in the past. So, I would say we are at 60% in terms of transport (13, IDI Provincial Health Office, MOH, Muchinga province).
Shortage of drugs/ commodities
Another key challenge that affected the work of the CHAs was shortage of drug and commodities. With commodities vital to their service provision, CHAs and health workers felt helpless when they failed to provide drugs to the community members, even when they were able to determine what the problem was. While the drug shortages seemed to be an overall system challenge, the community health work seemed to suffer more, since most of the facility-based drug needs would be prioritised over the community-based needs. As such community health work suffered a more severe case of drug shortages within the community health system. Also, delays in ordering supplies were noted, while some quantities that were ordered at the health facilities were not fulfilled, leading to shortages of drugs for both the facility and the community.
“The other one is short supply of RDTs, drugs, equipment, and commodities (…) So usually when we order for the facility, we don’t receive the same quantity ordered as we said that there is not enough supply. So, whatever is given to us, is what is shared between the community and facility” (253, IDI, Female CHA, Kawambwa District, Luapula Province).
Enabling environments and advocacy
Two themes were identified to contribute to the policy environment that shaping the operations of the CHAs. These include the recruitment process, deployment, and training policies.
Recruitment process
The recruitment for CHAs was standardised across all the 10 provinces based on the government set recruitment guidelines. Two CHAs were selected per health facility in collaboration with structures in the community in line with the recruitment guidelines. To be selected as a CHA, one should have completed Grade 12 and must have a school certificate. Further, the person should be a resident of the community and should preferably live near the health facility. It was reported that the CHA programme contributed to improving the recruitment process through strengthening communication process of selection guidelines and procedures during the training of CHA supervisors. It was reported that it was emphasised that the guidelines were supposed to be communicated by the District Office to the health facility prior to the recruitment of CHAs. Upon the receipt of the guidelines, the health facility through the community leaders advertised for the position of CHA within the various communities. Through such communication, the programme contributed to increased involvement of different community stakeholders in the selection of CHAs.
“Various actors from the Ministry of Health and within the communities were involved in recruiting the CHAs. At community level, participants reported that various actors at community level such as SMAGs, Community Based Volunteers and Neighbourhood Health Committees (NHC), traditional leaders were involved. At the NHC, they would select a candidate who had been working as a CHW in that community and submit the name to the health facility for further processing. “What I know is that they are selected from the community, and we also have community health workers like SMAG, NHCs and CBVs. These usually attend the community meetings where selection is taking place” (252, IDI, Female In-charge, Luwingu District, Luapula Province).
However, despite the robust process as described in the quotes above, some respondents complained that the selection procedures are not always followed. It was stated that some people that are selected as CHAs were not part of the community, and that in some instances advertisements for the CHA positions were never sent the communities. Sometimes CHAs were transferred from another health facility to another. However, in a few cases when a CHA was drawn from a different community, the community had reservations in trusting them, as they did not know them very well, and consequently some members found it hard to open their homes. Language barrier also played a huge role, in instances where a CHA was deployed from a far-flung place it was difficult for them to communicate effectively with the local community.
“It only becomes a challenge when you receive someone who is not from the community as I mentioned earlier because I don’t know the criteria they use when it comes to enrolment so you find that you receive somebody from somewhere else who doesn’t even know the language, so it becomes a challenge for that person to communicate with the people at the facility” (IDI, In Charge, Kalumbila District).
Resources and capacity building
This resources component includes human resources with appropriate personal, technical, and organizational capacities, and material resources such as essential infrastructure, medical and other commodities and technologies.
The CHAs undergo a standard one (1)-year training program. The training programme focused on prevention, promotion and basic curative care and consists of both theoretical and practical training components. To improve the quality of supervision, the Ministry of Health and CHAI with collaborating partners supported a training programme for supervisors who were working with CHAs. The training focused on helping CHA supervisors understand the duties, responsibilities, and roles of CHAs as well as how CHAs to how to supervise the CHAs. A total of 456 supervisors were trained.
Participants reported that the training for supervisors enabled them to support CHAs to carry out their duties accordingly. It was reported that the training helped the supervisors to work as good mentors to the CHAs by enhancing their understanding of the roles and duties of CHAs. This situation also improved the working relationships between CHAs and community members.
“The only training that we conducted I think like once, we take them for practical, we trained some members of staff because you know we are not entirely there with them, so we are trying to orient the members of staff on how to handle CHAs when we deploy them for practical’s and that training was only done once” (261, IDI Tutor, CHA Training School, Central Province).
Gaps with CHA supervision
Data from the qualitative interviews however showed that there was still needed to improve supervision processes. A few supervisors who had not been trained in supervising CHAs mentioned that they still did not fully understand the roles and skills of CHAs. They noted that the lack of knowledge had affected their ability to engage and support CHAs in their duties. Some supervisors for example could not understand the working schedule for CHAs and other key responsibilities of CHAs. This lack of understanding of CHA responsibilities affected effective supervision by some supervisors. Below are some reflections on the CHA supervision from two CHA supervisors who have never been trained.
“I have don’t know CHAs do. I just saw that a CHA was deployed at this health facility. From the time he came, I never offered any supervision because I am not sure about his level of competence” (Health facility staff, Luangwa District, Lusaka Province).
Some of the CHAs wished to have more supervision from their line managers. They noted that supervision would help provide guidance on their scope of work and motivate them conduct their duties.
“I wish I can be supervised more and allowed to spend most of the time in the community. Supervision in the community is poor so I wish to be supervised more” [227, IDI, Female, CHA, Kawambwa District, Luapula Province].
Community networks, linkages, partnerships, and coordination
This component includes community level structures and actors for that support CHAs in delivering services at community level.
Coordination among actors
The training that was provided to CHA supervisors in CHA duties enabled the supervisors to support CHAs to effectively work with community actors. This improved coordination was made possible through facilitating community meetings and allowing CHAs to participate in health facility meeting with communities. The transportation which was provided by the program helped CHAs to regularly visit the communities and engage the actors. The CHAs they engaged and worked with various actors at community level when delivering health services, including the traditional and religious leaders. The CHAs also worked with and received support from the health workers, NHCs, CBVs and local leadership in the community. Community based volunteers support by accompanying CHAs during household visits. CHAs also collaborate with other CHWs working on volunteer basis in conducting sensitization and outreach in the community.
“CHAs work with neighbourhood and community health workers. Then when they have a case in the community, the neighbourhood members they’ll communicate with CHA … the CHA can go and see that patient to see how the patient is and how the child is, so their role is to help this CHA to do their job because most of the neighbourhood, they know what is happening in the community” (06, IDI, Female, In-charge, Kalumbila District, North Western Province).
The CHAs reported that they were a bridge between the community and the health facility as they had good relationship with the community members, traditional leaders, and neighbourhood health committees. Since CHAs spent much of their time providing health services in the community hence, they ensured that relationship with the community and community leaders was good to enable them to do their duties smoothly.
“The working relationship is just ok. I have the HCC chairperson who is very free with me and helps me with whatever thing I ask. Most of the time we use his personal motor bike to go in deep areas and he does not refuse…so, we have a good health relationship with him and other community members because they know him very well” (58, IDI Female CHA, Luwingu District, Northern Province).
Open communication, trust and feeling of comfort with CHA services.
The strong community ties between the CHAs and the community was built on open communication and trust. The CHAs indicated that sometimes community members were more comfortable with them than with the health facility service providers. For example, in situations where community members were be shy to go for a service such as family planning, they would opt to go through the CHA as opposed to a health provider at the health facility. Further, the CHAs mentioned that when they communicated with the community, they listened and took into consideration community views, criticism, and corrections. These relationships and ability to reach out and understand community demands had earned the CHAs trust and respect among community members.
“I remember there was this time a woman came here, just family planning and then she was like, she found him here and then I was dispensing drugs here. She called me outside, no he is my child, i can’t go there and talk about family planning he will start wondering why I need family planning I even laughed with her that what will happen the time you will get pregnant and maybe in the labor ward you know. So, you find that they are more comfortable talking to me than the person they know” (182, IDI, Female, CHA, Kalabo District, Western Province).
Community members trusted the CHAs because they kept confidentiality with regards to the health issues, they discussed with them. They stated that they did not hear any of the issues they shared with the CHAs from other community members, which earned them their trust.
“I trust them, but I am not sure if they trust me. From what I have seen they trust me because they confide in me when they have problems, and they are able to complain when they have issues or when something goes wrong. For example, I told them to dig pits, toilets and make hangers for plates but the duration was short, so they complained and asked for a bit more time to do all the things I told them to do and they did them within a month” (227, IDI, Female, CHA, Kawambwa District, Luapula Province).
These feeling of trust were mainly attributed to the relationships that the CHAs has built with the community over time. Some community members stated that they were not afraid of asking the CHAs on anything because they didn’t alienate them, but rather they just corrected them. This made community members satisfied with what the CHAs had taught them. Further, community members explained that CHAs cared about the community members, and they are mature people who encouraged self - expression. The healthcare providers were equally of the view that the CHAs were accepted in the community. They stated that in some instances where the CHAs were not seen, the community members would directly go to the health facility and enquire about them. Further, the health providers indicated sometimes community members would prefer to be attended to by the CHAs.
‘’We have welcomed them because they are open to us, we are not afraid of them and regardless of what you want to ask, they don’t laugh at us, they just correct us. We are also very satisfied with what they have taught us. They come to our communities and start doing their job. They do not bring any problems and we accept them in the community the way they come. They care about the community members very much and they are mature people who can understand you regardless of how you say something.’’ (70, IDI NHC FGD, Nakonde District Northern Province).
Organizational and leadership strengthening
This organizational and leadership strengthening component discusses management and leadership systems for CHAs including CHA supervision system.
CHA coordination and supervision process
The Ministry of Health at national level supervises CHAs primarily through the Public Health Directorate’s Community Health Unit. The Unit collaborated with District Health Directors to ensure that supervisors at the facilities were supporting CHAs. The CHAs were required to work 80% of their time in the community providing health promotion, disease prevention and minor curative services and 20% at the facility providing primary health care services and reporting on their work. Through the CHSS program, supervisors were oriented on the importance of allowing the CHAs to spend 80% of the time in the community. Supervisors ensured that the community health system reports were completed and submitted by CHAs every month.
“Yeah, I think basically as an office (District Health Office), ours is just to see that the CHA is doing their work in the community. Yeah. And that the indicators monitored from this end, improve. Yeah, like issues to do with sanitation in the community and things like that.” IDI Male, District Health Office, Nakonde District, Northern Province).
The difficult in balancing work schedules at community level
Some participants stated that the CHAs did adhere to the established working schedule while other participants indicated that this arrangement was difficult to adhere to due to shortage of staff at the health facilities. The problem related to shortage of trained health workforce was more prominent rural areas which meant that CHAs were mostly working at the health facility. This prevented the CHAs from delivering health in the community as expected.
“They deliver but it is just the challenge of inadequate human resources, they have been given that 80% they need to go in the community and 20% it’s here at the health facility, now in situations that the in-charge is not there and the community is big and then the government just brings two or one worker so when they are not there it is a challenge in terms of congestion that is why a person can fail to meet the 80%” (82, IDI, FGD, Community Members, Luwingu District, Northern Province).
In a few communities with shortage of trained health workers, a few participants complained that they had never seen CHAs work in the community. The challenge of CHAs not to regularly working in the community had made it difficult for some community members to remember CHA responsibilities as they did not have the opportunity interact with the CHAs in the community on a regular basis.
“Even in the community, I have never met them before that’s what I can say so, no wonder I am failing to answer other questions because I had met them and seen their work. It would have been very easy answering the questions but now it is very difficult because I have never met them” (03, FGD, HCC- NHC, Kalumbila District, Northwestern Province).
Monitoring and evaluation and planning
The last component of the model is about the involvement of CHAs in M&E systems, including collection of community level data.
Facilitating routine collection and timely reporting of data
Within the community, CHAs collected information from community-based volunteers including information on patients, resources, local priorities, maternal deaths, and pregnancies. Conducting such roles enabled CHAs to provide comprehensive routine data from the community to the health facility. This health information helped the community health systems to prepare for and effectively respond to health issues in the community.
It was further suggested that the coming in of the CHAs did not only facilitate comprehensive availability of data but also ensured timely reporting of data since the CHA was required to provide information monthly, using the HIA4A information system. However, in some facilities CHA reports were reported as incomplete due to missing data thereby making it difficult for supervisors to provide quality feedback. Previously, the NHCs were responsible for updating the facilities with information about health messages disseminated, household visits and outreach services. One participant highlighted how that of routine data collection from the NH to the CHAs as helped to improve the process as follows:
“It has worked well because we are getting the information from the direct person who is in contact with the community rather than it used to be, whereby, it was entirely by the NHCs who were sometimes were reporting or they didn’t report this month, so we discovered that there were a lot of lapses. But with them they are constantly reporting whatever they do in that month” (242, KII, Male, Community Focal Point Person, Luapula Province).