Evaluating community health workers performance in the prevention and control of malaria in Livingstone District,Zambia: a bottle neck analysis

Community Health Workers (CHWs) are an important human resource in improving community malaria intervention coverages and success in reducing malaria incidence has been attributed to them. However, despite this attribution, malaria resurgence cases have been reported in various countries including Zambia. This study evaluates fidelity of the CHW strategy through evaluation of performance, quality of service and other moderating strategies in malaria prevention and control in Livingstone district highlighting specific factors that are associated with effective implementation of the CHW strategy in malaria programs. A mixed method concurrent cross-sectional study based on quantitative and qualitative approaches was used to evaluate performance and service quality for the two catchment areas of Nakatindi and Libuyu in Livingstone district. For the quantitative approach, 34 CHWs were taken as complete enumeration with evaluation based on CHW knowledge on malaria, report submission, health education, testing and treating. Service quality was assessed based on active detection, diagnosis and treatment, prescription of drugs, follow up and dissemination of malaria preventive messages and actions. A community survey of 464 participants was also done to assess community responsiveness. Two focused group discussions from CHWs and three key informant interviews from the CHW supervisors were done for moderating factors to the CHW strategy for malaria. The study findings indicate that overall implementation fidelity was low with only 5(14.7%) of the CHWs having good performance and least good quality service while 29 (85.3%) performed poorly with substandard service. This however varied with specific indicators being evaluated. For malaria preventive actions by CHWs; 24(70.5%) of the malaria CHWs reported to practice preventive actions and vector control measures. Being married, record for reports, supervision, and work experience were found to be significant factors associated with performance, and no variable was found to be a significant factor for quality service. From the survey, CHWs have poor coverage for malaria index case service response and that a lot more services are rendered by the CHW which are not documented in the CHW records with ITN distribution as the most service received by the community (75%) and 59% for IRS. Lack of supplies, insufficient remuneration and lack of ownership by the supervising district were main moderating factors that were reported to hinder ideal implementation of the CHW strategy. Fidelity to the malaria CHW strategy was low as performance and quality of service was poor and substandard respectively. Strategies to improve responsiveness by the community and improvement in the organizational system with regards to facilitation of the malaria CHW program in terms of supervision, stock supply and recruiting more CHWs on a more standardized level of recognition and remuneration would render an effective quality implementation of the CHW malaria strategy for this setting. Key words: Community Health worker, Performance, Evaluation, Malaria, Assessment, Implementation, fidelity, quality, adherence, policy