Learning from past mistakes, and advocating for government led community health worker programmes

About On Call Africa

On Call Africa aims to improve health outcomes for marginalised rural communities in Zambia by improving access to quality healthcare, and striving for quality care as close to the home as possible. On Call Africa strives to support the achievement of national strategic objectives, while ensuring that we align with international best practice, and listen to, and remain responsive to the communities that we support.

To achieve our goals, we focus on improving access to, and quality of care at rural healthcare facilities, strengthening community health programmes, and influencing policy and practice.

The situation in rural Zambia

Around the world in low- and middle- income countries, more than 15 million people die each year from otherwise preventable causes (Kruk M. et al., 2018). Poor access to quality healthcare is a particular challenge in rural Zambia, where in 2014, 46% of rural households in Zambia still lived outside a radius of 5km from a health facility, compared to only 1% for the urban households (Zambia Ministry of Health, 2019). In the communities that we target, households can be as far as 40km from the nearest healthcare facility, a significant challenge exacerbated by poor roads and limited transport.

For those that can access healthcare facilities in rural communities, challenges remain. Health worker density in rural Zambia is 12.2 to 10,000 people, compared with the 22.8 minimum target set by WHO for universal health coverage (Zambia Statistics Agency, 2018). Health workers that do operate, do so in rural health facilities lacking the infrastructure and equipment needed to provide basic health services to the communities they serve (Zambia Ministry of Health, 2019).

The Zambian Ministry of Health have ambitious plans to bring healthcare as close to the home as possible and hope to have a health facility within 5km of all residents. However, they lack the resources and finances to put this into practice in the medium-term, and for some communities this would represent significant investment for a small number of people, due to the dispersed nature of the population in some rural communities.

The Zambian Ministry of Health have ambitious plans to bring healthcare as close to the home as possible and hope to have a health facility within 5km of all residents. However, they lack the resources and finances to put this into practice in the medium-term (...).

Why we work with community health workers

On Call Africa was established in 2010 by a team of doctors and international development experts who recognised the need for improved access to healthcare in rural communities in Sub-Saharan Africa. Zambia was selected as the starting point for our work because it had the lowest ratio of doctors to people in the region at that time, and because of the dispersed nature of rural populations.

At our inception On Call Africa delivered mobile medical clinics in partnership with the Ministry of Health, targeting some of the hardest to reach rural communities once per month. It quickly became apparent that there was need for more regular medical support for communities who had to travel long distances to healthcare facilities with limited transport options, and that health facility staff did not have capacity to deliver this. After consulting with local District Health Offices we developed a general primary care CHW programme based on international best practice, to empower passionate and skilled community members to provide basic health services.

Our CHWs underwent a 12-month training programme to support them to carry out health promotion, identify danger signs and make referrals, carry out basic diagnosis and treatment, and crucially to work within the health system. Nurses and clinical officers attended training alongside our CHWs to support their supervision and to get a good understanding of how they could enhance health service delivery at community level.

We were aware that multiple CHW programmes existed in some of the communities that we operated, but felt there was need to provide general primary care training to existing CHWs, or new ones in communities where non existed. This is because the existing CHW programmes operated in silos, with some offering as little as two weeks training on a specific disease. What we found is that some communities might have a TB and HIV CHW, a malaria CHW and a safe motherhood CHW for example, but those CHWs were not equipped to identify and refer, or support, community members who presented with other concerns. This meant that multiple CHWs may be needed to visit just one household, and urgent health needs may be missed.

In the communities that our CHWs operate we have had fantastic feedback from health workers, the District Health Office, and crucially from the community members where they live and work. Our CHWs are embedded in and live in the communities that they operate, enabling them to support access to health services for their families, neighbours, and wider community. Health workers have provided feedback that they see our CHWs as crucial elements of their health systems, where they can call on them to support the delivery of Ministry of Health services, and act as a crucial bridge between communities and the health facility. For community members they have helped to make urgent referrals, treat and support self-management of basic health conditions, and promoted health through the dissemination of information. CHWs are also able to highlight outbreak of disease and support healthcare facilities to respond accordingly.

We were aware that multiple CHW programmes existed in some of the communities that we operated, but felt there was need to provide general primary care training to existing CHWs, or new ones in communities where non existed. This is because the existing CHW programmes operated in silos, with some offering as little as two weeks training on a specific disease.

Health workers have provided feedback that they see our CHWs as crucial elements of their health systems, where they can call on them to support the delivery of Ministry of Health services, and act as a crucial bridge between communities and the health facility.

Challenges facing CHWs in Zambia

Community health workers form a vital part of the health workforce in Zambia, providing a low-cost solution to the national health worker shortage. However, this is currently a deeply fragmented and incohesive system, with approximately fifteen cadres of volunteers working in different vertical programmes. The training for each of these groups of CHWs differs in content, length, and intensity. Selection criteria are not always clearly stipulated, and there are no standard guidelines for incentives or working hours for volunteers, which differ depending on the funder, implementing partner and districts in which the work is implemented (Zambia Ministry of Health, 2019).

Community structures are in place to supervise CHWs, provide community health services, and to hold government accountable for the delivery of services. However, these structures are not well supported and there is no formalised training to ensure the CHWs work effectively. There are also challenges at community level in ensuring timely and accurate record keeping supporting decision making.

In 2018, the Ministry of Health established the Community Health Unit to help tackle fragmentation and improve quality of services at community level. Using international best practice guides provided by the Community Health Impact Coalition, and organisations like WHO and USAID, the Community Health Unit developed a robust and exciting strategy to help address challenges in the community health system and to focus partner efforts.

However, the unit was established as a sub-directorate within the public health directorate and does not have the same level of influence as some of the directorates who have established their own CHW programmes, making it challenging for the Community Health Unit to make some of the changes outlined in their strategy. This problem is exacerbated by the Community Health Unit not having its own significant funding stream and being dependent on the funds and support of NGOs. The same NGOs often contribute to some of the fragmentation within Community Health by running their own CHW programmes that operate independently of the health system.

As we have grown as an organisation, we have shifted our focus from service delivery to health system strengthening, and as a result we now engage more with the Ministry of Health at all levels of the health system. As we increased our understanding of the challenges facing the Community Health Unit in strengthening community health programmes, we recognised the role we were playing in contributing to fragmentation. While our efforts to deliver training that focused on general primary care had a strong local impact, we were negatively contributing towards further complexity in the health system by adding an additional cadre.

This problem is exacerbated by the Community Health Unit not having its own significant funding stream and being dependent on the funds and support of NGOs. The same NGOs often contribute to some of the fragmentation within Community Health by running their own CHW programmes that operate independently of the health system.

How we hope to support strengthening of CHW programmes in Zambia

We recognise the need for better co-ordination between NGOs and Ministry of Health directorates to bring about the changes needed to help CHW programmes to realise their potential in Zambia. We also acknowledge that the Community Health Unit are best placed to deliver that change, through a government led approach. As such, we focus our efforts on supporting the Community Health Unit to achieve their national objectives, and channel our support through national Technical Working Groups to ensure co-ordination.

While we continue to support our existing CHWs, we have now halted plans for training of additional CHWs to ensure that any training we deliver aligns with the aims of Ministry of Health. As support for the Community Health Unit has grown amongst NGOs, and with Ministry of Health, we have seen positive developments over the last 12 months. In 2022 we are expecting to see the launch of the following key developments:

• A legal framework for CHWs to operate within the Zambian health system
• Standardised incentives for CHWs
• A standardised community health service package
• A digital health programme for CHWs to enhance service deliver and improve reporting and data flows.

We recognise the need for better co-ordination between NGOs and Ministry of Health directorates to bring about the changes needed to help CHW programmes to realise their potential in Zambia. We also acknowledge that the Community Health Unit are best placed to deliver that change, through a government led approach.

We are proud of the small role that we have played in these developments and excited to see how these developments can help to formalise and strengthen the role of CHWs in Zambia. We intend to support the role out of these key developments and support the development of training resources to help convert the community health service package into standardised general primary care training for all CHWs in Zambia.

We are excited to see that WHO guidelines (WHO, 2018) have been developed to help guide NGOs and government, and that there are growing movements such as the Community Health Impact Coalition in existence to advocate for CHWs. We hope that this will not only promote best practice, but also help to create urgency around the importance of high functioning CHW programmes, and the need for CHWs to be properly renumerated.

References

• Kruk M., et al. (2018). Mortality due to low-quality health systems in the universal health coverage era: systematic analysis of amenable deaths in 137 countries. Lancet. https://www.thelancet.com/action/showPdf?pii=S0140..
• Zambia Ministry of Health, C. H. (2019). National Community Health Strategy 2019-2021. Zambia: Ministry of Health. http://www.nac.org.zm/ccmzambia/download/community...
• Zambia Statistics Agency, M. o. (2018). Demographic and Health Survey 2018. Lusaka, Zambia, and Rockville, Maryland, USA: Zambia Statistics Agency, Ministry of Health Zambia, and ICF. https://dhsprogram.com/pubs/pdf/FR361/FR361.pdf
• WHO. (2018). WHO guideline on health policy and system support to optimize community health worker programmes. Licence: CC BY-NC-SA 3.0 IGO.: World Health Organisation. https://www.who.int/publications/i/item/9789241550...