Elsevier

Health Policy

Volume 65, Issue 2, August 2003, Pages 109-118
Health Policy

Poor performance of community health workers in Kalabo District, Zambia

https://doi.org/10.1016/S0168-8510(02)00207-5Get rights and content

Abstract

Objective: To determine the factors contributing to low performance of community health workers in Kalabo District, Zambia. Methods: In a cross-sectional descriptive study, 86 community members, 27 community health workers and nine rural health centre staff were interviewed using semi-structured questionnaires. Other methods were focus group discussions and checklists. Data analysis was done manually. Results: The low performance of community health workers is a real problem for Kalabo District. The two most important factors are the irregular and unreliable supply of drugs and selection of the wrong people to be trained for community health workers. Conclusion: Though initially implemented as such, the comprehensive approach of the primary health care project is no longer functioning in Kalabo. Community health workers are mainly valued because of their curative services. Communities do not properly follow the official criteria for selection of people to be trained, but have other considerations. Strategies will have to be formulated to rehabilitate the programme, mainly focussing on these two findings. Other factors, like inadequate community support and inadequate supervision, were mentioned by many contributors.

Introduction

The Primary Health Care (PHC) approach was adopted as the most rational strategy for healthcare delivery by all countries of the world in 1978. The principles of PHC were described in the Declaration of Alma-Ata [1]. PHC seemed to guarantee more equity in health service delivery and encouraged the participation of the people, the consumers of health care. It aimed to provide socially and culturally appropriate care and it stimulated preventive care. PHC was a revolution in the concept of health care [2].

Community health workers played a key role in the functioning of PHC. People from the villages were selected and trained to form the link between the communities and the established health systems. Community health workers were the living embodiments of the principles of PHC. Many community health worker programmes were initiated all over the world and first reports in literature were mostly very positive [3].

During the first years of its introduction, PHC was hailed as the panacea. Lyrical words about the conceptual change in health care were published [4].

After initial enthusiasm, different insights arose on how to implement PHC. By reinterpreting the concept of PHC, various professional groups, politicians and activists tried to assert their influence on PHC. The most important discussion was between those believing in the comprehensive PHC approach and those having more faith in the selective approach [5], [6].

Critical evaluations were also published about the functioning of community health workers. Community health workers were not able to decrease mortality [7]. The services provided by them were not consistent enough to have substantial impact and the quality of services was poor [8]. Community health workers' services were under-utilised and they were by-passed in case of serious disease [9]. Communities expected more emphasis on curative services and there was no demand for health prevention or promotion [10]. Larger collaborative research studies concluded that most community health worker programmes had four general problems: unrealistic expectations, poor initial planning, problems of sustainability and difficulties in maintaining quality [11], [12]. In the 1990s, interest in community health worker programmes decreased, whilst most programmes continued to run, with or without lessons learned from mistakes in the past.

It is clear that the PHC concept and the role community health workers should play, were not a blueprint. The PHC concept is an ideology, but the concept did not give enough suggestions as to how this can be implemented in a situation where there are already systems that create and meet the needs of people [13]. It was left to individual countries to decide how to introduce PHC and this is what caused considerable confusion as well.

The PHC programme in Zambia started in 1981. In a national policy paper [14], the Government of Zambia designed the routes along which the PHC approach should be implemented to achieve the Zambian goal: “Make basic health care available to all the people in the community in an acceptable way and with their full participation”. Five principles were laid down as the basis of this policy:

  • 1

    Stimulation of equity of all people;

  • 2

    Community participation;

  • 3

    Predominantly aiming at prevention of diseases;

  • 4

    Making use of appropriate techniques;

  • 5

    Inter-sectoral approach of community development problems.

Community health workers were seen as the key players in the new approach. To achieve full participation of the people, community health workers got the responsibility to explain, educate and motivate the people.

The Zambian government decided to focus on the Western Province to introduce the programme and Kalabo District became one of the pilot districts for the introduction of the concept of community participation in health issues. An essential healthcare package, accessible to individuals and families, was introduced. Kalabo became widely known and famous because of its community health worker programme. The District started training community health workers in 1983. The first 12 community health workers were selected from areas with active village health committees in place. Selection criteria were: a respected and trustworthy person, preferably female; around 30 years of age and not above 50; living in the community; willing to work on a voluntary basis; able to read and write in the local language. Community health workers had tasks in promoting proper food production and basic sanitation, to detect risk groups, prevention of common illness, to give first aid treatment and treat minor ailments, to organise the community and to collect and maintain simple community data. Initial evaluations and reports were very positive and the pro-active role of communities was obvious [15].

Later on, as in the rest of the world, communities and the District Health Management Team in Kalabo District have not been satisfied with the performance of the community health workers. Most preventive and promotive programmes have finished, diagnostic skills of health workers have deteriorated, keeping of health records and reporting has been poor and the disease burden of preventable diseases has increased [16]. Several interventions to improve this situation have already been implemented, but most of them have not born fruit. Because of the importance of this cadre in the Health Reform package, many resources have already been invested in this area, by both the health sector and other stakeholders. Insufficient community support and supportive supervision, as mentioned in studies in other areas as well [17], [8], have always been considered the most important factors to fight in Kalabo. Selection criteria for community health workers could be another factor.

Section snippets

Objectives

The objectives of the study were:

  • 1

    To determine the performance of the community health workers.

  • 2

    To determine the impact of some known factors, which could influence performance of community health workers in the Kalabo PHC project, namely poor diagnostic skills, inadequate supportive supervision, irregular logistics and supply of drug kits, inadequate community support and poor selection criteria.

Study area and population

Kalabo District is one of the seven districts in the Western Province of Zambia, bordering with Lukulu District in the north, Mongu District in the west, Senanga and Shangombo Districts in the south and Angola in the east. The district covers an area of 17,447 km2 and has a population density of only seven people per square kilometre, making a total population of 114,996 [18].

The district has two hospitals and 14 rural health centres. At the time of the study, there were 143 community health

Results

A total of 122 people were interviewed, unevenly distributed over the four mentioned groups: 27 community health workers, 60 community members, 26 neighbourhood executives and nine rural health centre staff. Sex distribution was in acceptable ranges with 44% females and 56% males; 68% were married, 15% were single, 10% were divorced or separated and 7% were widower or widow. The age distribution of the respondents was as follows: 6% between 61 and 80 years, 43% between 41 and 60 years, 39%

Discussion

The magnitude of the problem, poor performance of community health workers, was clearly confirmed. Only between 38 and 48% of the community health workers are active. It turned out to be impossible to objectively judge the quality of work delivered by the active community health workers, because of the diverging expectations from community health workers in the communities and the lack of defined outcome indicators to measure the performance.

In the community, 95% mentioned that the quality of

Conclusions

The once famous community health worker programme of Kalabo District, being part of the Western Province Primary Health Care project, has almost completely collapsed. The majority of community health workers are inactive and the programme has low priority, both at district and national level, leading to unacceptable weaknesses in supply systems for drugs, equipment and logistics.

The two most important factors related to the dysfunction of the programme are shortage of drugs and poor selection

Acknowledgements

We thank the Central Board of Health and the Royal Netherlands Embassy for facilitating the course in District Health Management; Dr. A.M. Ngwengwe and Dr. S.M. Khunkuli from the University of Zambia, Mr. P.A Musokwa for facilitating the study; Mr. M. Mukelabai, Mr. L. Lubilo and Ms. P. Manganya for their help in data collection, Ms. E. Kashumba for her help to compile the final study report and Mrs. N. van Beelen for her support with the final editing of the text.

References (23)

  • A. Menon

    Utilization of village health workers within a primary health care programme in the Gambia

    The Journal of Tropical Medicine and Hygiene

    (1991)
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