Global Public Health An International Journal for Research, Policy and Practice

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An exploration of the feasibility, acceptability, and effectiveness of professional, multitasked community health workers in Tanzania Colin Baynes, Helen Semu, Jitihada Baraka, Hildegalda Mushi, Kate Ramsey, Almamy Malick Kante & James F. Phillips To cite this article: Colin Baynes, Helen Semu, Jitihada Baraka, Hildegalda Mushi, Kate Ramsey, Almamy Malick Kante & James F. Phillips (2016): An exploration of the feasibility, acceptability, and effectiveness of professional, multitasked community health workers in Tanzania, Global Public Health To link to this article: http://dx.doi.org/10.1080/17441692.2015.1080750

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Date: 29 February 2016, At: 09:37

GLOBAL PUBLIC HEALTH, 2016 http://dx.doi.org/10.1080/17441692.2015.1080750

An exploration of the feasibility, acceptability, and effectiveness of professional, multitasked community health workers in Tanzania Colin Baynesa,c, Helen Semub, Jitihada Barakac, Hildegalda Mushic, Kate Ramseya,c, Almamy Malick Kantea,c and James F. Phillipsa Mailman School of Public Health, Columbia University, New York, USA; bMinistry of Health and Social Welfare, Dar es Salaam, Tanzania; cIfakara Health Institute, Dar es Salaam, Tanzania

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ABSTRACT

ARTICLE HISTORY

Despite four decades of global experience with community-based primary health care, the strategic details of community health worker (CHW) recruitment, training, compensation, and deployment remain the subject of continuing discussion and debate. Responsibilities and levels of clinical expertise also vary greatly, as well as contrasting roles of public- versus private-sector organisations as organisers of CHW effort. This paper describes a programme of implementation research in Tanzania, known as the Connect Project, which aims to guide national policies with evidence on the impact and process of deploying of paid, professional CHWs. Connect is a randomised-controlled trial of community exposure to CHW integrated primary health-care services. A qualitative appraisal of reactions to CHW implementation of community stakeholders, frontline workers, supervisors, and local managers is reviewed. Results highlight the imperative to plan and implement CHW programmes as a component of a broader, integrated effort to strengthen the health system. Specifically, the introduction of a CHW programme in Tanzania should draw upon community structures and institutions and strengthen mechanisms to sustain their participation in primary health care. This should be coordinated with efforts to address poorly functioning logistics and supervisory systems and human resource and management challenges.

Received 21 November 2014 Revised 30 April 2015 Accepted 5 June 2015 KEYWORDS

Community health workers; Tanzania; health systems; primary health care; implementation research

Introduction Despite progress throughout Africa, most countries will not achieve their health-related Millennium Development Goals by 2015. In response, health policy deliberations in this region have focused on achieving universal health care by training and deploying frontline health workers to reach rural populations with essential services (World Health Organization, 2010). Three priority areas have been identified: (1) strengthening health systems (Travis et al., 2004); (2) shifting primary health-care tasks from specialised cadre to less-specialised workers (World Health Organization, 2006); and (3) eliciting community CONTACT Colin Baynes © 2016 Taylor & Francis

[email protected]; [email protected]

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participation in primary health care (Rosato et al., 2008). Based on evidence that community health workers (CHW) contribute to improved population health in workforcedeprived settings, investment in this strategy has expanded in recent years (Community Directed Interventions Study Group, 2010; Global Health Workforce Alliance, 2013; Lehmann & Sanders, 2007; Perry, Shanklin, & Schroeder, 2003). Commitment to CHW has origins in the co-occurrence of independence movements with international disease-control initiatives (Levine, 2007). The 1978 World Health Assembly was transformational, generating national programmes that attempted to organise health services from the periphery upward rather than clinical, top-down, urban-focused approaches (Bender & Pitkin, 1987; Gilson et al., 1989; Mahler, 1981; World Health Organization, 1978). However, the global economic recession and debt crises of the 1980s catalysed commitment to cost recovery schemes and reliance on affordable volunteers to focus on particular service components (Berman, Gwatkin, & Burger, 1987; Rifkin & Walt, 1986). As these approaches struggled, strategies arose which consigned priority to sector-wide strengthening of primary health-care systems (Peters, Paina, & Schleimann, 2013; Walt, Pavignani, Gilson, & Buse, 1999). Several global initiatives contributed to this trend, such as the Expanded Programme for Immunizations and the Integrated Management of Childhood Illness (IMCI) initiative (Armstrong Schellenberg et al., 2004; Bryce, Victora, Habicht, Vaughan, & Black, 2004; Lambrechts, Bryce, & Orinda, 1999; Nicoll, 2000). Although CHW programmes were a frontline strategy of disease-focused initiatives in the 1990s (Hall & Taylor, 2003), limitations of ‘vertical programmes’ soon became apparent. This led to ‘sector-wide’ strategies involving professional CHW who provide a range of primary health-care services across the ‘continuum of care’ (Standing & Chowdhury, 2008). This paper examines the acceptability and feasibility of such a programme in rural Tanzania. Qualitative research assesses the coherence of incorporating CHW into the wider district health system, the responsiveness of the strategy to community preferences and needs, and participation of the community in the CHW programme.

Background The Tanzanian health-care system is organised at the district level, with care extending from district referral hospitals to ward-level health centres and dispensaries that provide outreach to communities, often with support from volunteer workers. However, human resource shortages have constrained the implementation of this plan (Kurowski, Wyss, Abdulla, & Mills, 2007). There is a legacy of deploying CHW to solve this problem, but their service coverage, work packages, and geographic distribution has been variable, and most have been absorbed by vertical programmes. With the goal of resolving this problem, the Government of Tanzania promulgated the Primary Health Care Services Development Policy (Swahili acronym, MMAM) in 2007. This reform programme called for a single, official, national cadre of CHWs, but did not specify a programme design or a strategy of how CHWs would be introduced in the health system. The Connect Project was launched in 2011 to address these gaps by operationalising the CHW component of the MMAM and evaluating its health impact (Ramsey et al., 2013). Connect was conceived between 2009 and 2011 through a dialogue across policy-makers, programme implementers, and academia. The Ministry of Health and Social Welfare (MOHSW), the Tanzanian Training Centre for International Health (TTCIH), the

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Ifakara Health Institute (IHI), and the Mailman School of Public Health at Columbia University (MSPH) formed a partnership for developing, implementing, and evaluating an approach to CHW deployment that could serve as a model for national programming. The MOHSW and TTCIH designed the CHW service package, role, and training programme, and the latter went on to implement the training. The IHI and MSPH provided technical assistance to the programme design and led the programme evaluation. Joint partnership meetings were convened to finalise design issues and implementation plans. This involved Council Health Management Teams (CHMT) from the pilot districts of Kilombero, Rufiji, and Ulanga who went on to implement the intervention, with embedded technical support from the IHI. With this, Connect recruited, trained, and deployed a cadre of 142 Wawezashaji wa Afya ya Jamii, or Community Health Agents (Swahili acronym, WAJA), in three successive trainee batches. All WAJA were selected by way of community election, had attained four years of secondary education, and received nine months of primary health-care training. After successfully completing the training, WAJA were formally hired as salaried local government employees. The services provided by WAJA include family planning education, re-supply of oral contraceptives and condoms, sexually transmitted infections/HIV prevention education, safe motherhood and essential newborn care counselling, and IMCI, which includes community case management of malaria, pneumonia, and diarrhoea (iCCM). The IMCI component involved training WAJA to follow specific protocols to identify and treat sick children in the initial stages of uncomplicated malaria, pneumonia, or diarrhoea. Treatment included ACT Coartem, amoxycillin, and oral rehydration salts with zinc sulphate, respectively. To support CHW deployment, Connect developed supervisory and community governance systems, launched information and monitoring operations, and implemented logistics support. WAJA receive supervision from a ‘health facility supervisor’ who has at least two years of clinical training, and a ‘village supervisor’ who is a member of the Village Government and appointed to this role by the Village Executive Officer. All supervisors received an orientation to the project and training in supportive supervision. To evaluate Connect, the IHI and MSPH designed a randomised-controlled trial. Accordingly, WAJA were deployed to 50 intervention villages dispersed across three intervention districts. Fifty-one comparison villages provide a basis for statistical evaluation of the demographic and health impact of WAJA deployment. All 101 villages are located in areas of the IHI Health and Demographic Surveillance System (HDSS), which monitors the under-five and newborn mortality impact of WAJA deployment as well as other key maternal, child, and newborn health indicators. Statistical research is augmented with a mixed-method process evaluation that contextualises and explains the demographic outcomes. The current analysis is drawn from a qualitative component of the process evaluation which elicited feedback from community and health systems stakeholders during Connect’s first year of operation.

Methods The study area The HDSS operates in Kilombero, Ulanga, and Rufiji districts. Kilombero and Ulanga are 400 kilometres west from Dar es Salaam in Morogoro Region. Rufiji district is located in the coastal region, south of Dar es Salaam (Figure 1).

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Figure 1. Map of Tanzania and project districts.

Conduct of qualitative study The evaluation of Connect was conducted by IHI and MSPH staff. Evaluators from neither organisation were directly involved in the implementation of Connect. Moreover, MOHSW officials were not involved in field activities. Qualitative data were gathered in 6 out of the 50 intervention villages. These villages were selected based on population size, numbers of WAJA deployed, rural or urban characteristics, as well as information on service delivery coverage. Village-level participants include Village Executive Officers, Village Chairpersons, Traditional Birth Attendants, Village Health Workers (Wahudumu wa Afya Vijijini, Swahili acronym WAVI), village supervisors of WAJA, hamlet leaders, and WAJA themselves. Health-care providers and managers were enrolled if they had received orientation and supervision training from the project, or if they were members of the CHMT. Sampling procedures were stratified by district (i.e. Ifakara and Rufiji) and community size. Twenty-two focus group discussions (FGD) and 56 semi-structured interviews were conducted in Swahili by experienced interviewers who recorded and transcribed responses. Translation from Swahili to English was conducted by experienced translators. Data were collected during the first year of project implementation (Table 1).

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Interview and focus group guides were developed in English and translated into Swahili during interviewer training to ensure that questions were understood and that interviewers could accurately phrase them in Swahili. Community and district representatives assisted in the recruitment of focus group participants. Findings from the discussions were transcribed, reviewed to extract preliminary findings, and utilised to finalise semi-structured interview guides, which were used for gathering data from villagers, clinical staff, and district authorities. Local residents supported the recruitment of interview participants.

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Data analysis Six social scientists reviewed transcripts to identify themes, and constructed a codebook around three research questions: (1) Can WAJA be coherently integrated into the wider, district health system (i.e. how is the system able to absorb a new community-based cadre)? (2) How do health system and community stakeholders perceive the shifting of tasks from clinics to WAJA? (3) Does WAJA implementation sustain community participation in the programme? Practical framework analysis (Srivastava & Thomson, 2009) and grounded theory analysis (Corbin & Strauss, 1990) were combined to pursue ‘open’ coding to identify patterns and relationships within and across transcripts. ‘Axial’ coding procedures, derived by integrative interpretation of open-coded texts, drew upon these data to form matrices for each research question to validate and refine explanatory patterns which had emerged. During the final and ‘selective’ stage, these matrices were examined, leading to a refined explanation for each research question. Table 1. Qualitative systems appraisal participants. Participants Key informant interviews Village Executive Officer Village Chairperson Traditional Birth Attendant WAVI WAJA Village Supervisor CHA Hamlet Leader District Medical Officer Medical Officer In-charge District WAJA Coordinator District Reproductive and Child Health Coordinator District Pharmacist District Health Information Officer District Health Secretary Chair of Council Health Services Board Health facility in-charge Clinical Supervisor of WAJA Focus group discussions Women with a child under age 1 Men with children under age 5 CHA Members of village government Village supervisors Clinical supervisors TOTAL

Kilombero/Ulanga

Rufiji

2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 2 2

2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 2 2

2 2 2 2 2 1 39

2 2 2 2 2 1 39

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Ethical considerations Permission for this study was accorded by the ethical review boards of the Ifakara Health Institute (IHI/IRB/No. 16-2010), the National Institute for Medical Research’s Medical Research Coordinating Committee (NIMR-CC) (NIMR/HQ/R.8a/Vol.IX/1203), and the Institutional Review Board (IRB) of Columbia University Medical Center (Protocol AAAF3452). Research assistants administered formal informed consent procedures and obtained the signature or thumb print of subjects to confirm willingness to participate.

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Can WAJA be coherently integrated into the wider, district health system? According to clients, providers and managers, WAJA address the need for convenient care that is suited to client needs: When WAJAs come, they ask you, what is the problem with your child, have you taken her to the facility? You say no, the child will be examined and if WAJA cannot manage the condition she will tell you to go the facility to do lab tests, but if you don’t get medicines come back to me [WAJA] … if the condition is not severe, she [WAJA] gives you medicines rights away. (FGD, Women, Kilombero)

However, clients reported lapses in the referral process owing to remoteness of clinics and disrespectful treatment by clinic staff. If you go to our dispensary once you meet the providers and you tell her that my baby had fever since yesterday, they start yelling ‘why didn’t you come since yesterday?’ You tell that that it started at night, and I’m staying far away from here. They wouldn’t listen to you; you explain that the fever started late in the evening, and I have come this morning. Kindly give me medication. They won’t listen. Then they tell you ‘you are arrogant, go away.’ You won’t get any medicine. (FGD, Women, Rufiji)

Facility-based workers reported that WAJA rationalised the utilisation of facility-level services. One noted: Another motivation there at my center, even if we will say there are [under-fives] who come, but those who come are in serious condition, but there they are fewer because already WAJA have [been] introduced, but in previous days when a child would come will be in bad condition, but nowadays the situation is better. (Clinical Officer, Kilombero)

WAJA described challenges coordinating client case management with pharmacy workers in the study area: We as WAJAs were taught that as much as we give family planning pills, we should not initiate clients’ use. We are allowed to refill to clients who have been assessed in health facility; but in the drug shop, the pharmacy worker does not do any assessment to the client. It became a problem to us because we tell clients we are not allowed to give you unless you have done some tests in the health facility, but they go to the shops, buy medicine, and consume them, because all they [pharmacy workers] care about is money. (FGD, WAJA, Kilombero)

Similar problems arose with respect to anti-malarial treatment: On malaria treatment, pharmacy workers at medicine outlets do not provide proper education. They give half dose because the mother will say she [doesn’t have enough] money.

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The [pharmacy worker] is doing business will give maybe SP one tablet, or Alu three, but do not educate so that you can get a proper treatment for your fever. (FGD, WAJA Facility Supervisors, Kilombero)

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Whereas WAJA provide free treatment for children, pharmacy workers frequently do so for profit, often dispensing less than a full course of anti-malarials, or even selling products that are no longer the standard of care. Similarly, pharmacy workers dispense oral contraceptives without clinical referral, contravening policy and creating discord between WAJA and their clients who think WAJA should do the same. Challenges arose from chronic unavailability of pharmaceuticals and clinical service fees. According to a WAJA supervisor, with WAJA deployment, ‘The number of patients has increased at the facility and there is no medicine’ (WAJA Facility Supervisor, Rufiji). Men from Rufiji reiterate this point: I know WAJA as a person who provides first aid in this village and we wish he could have been trained more, so that these village problems will decrease and we will have no more need to go to the health centres, this is because there are nothing we get from the health centres and we get a lot from WAJA. (FGD, Men, Rufiji)

Facility supervisors of the WAJA struggled to meet their supervision targets. According to one supervisor, a Clinical Officer, Most of the time I communicate with [WAJA] by phone because of the activities at the [health] center. As a Clinical Officer you have many things to do, and you are the only one at the facility. (FGD, Facility Supervisor, Kilombero)

Nevertheless, respondents typically endorse the introduction of WAJA by noting ways in which their role improves the health system. According to a district official: We automatically accepted the program, and we thought it is a good thing. In the community I think it is well accepted. I have heard people start saying ‘it is better with the WAJAs, they listen to you. At the same time, they assess you. It is better than going to the health facilities, where they tell you “there is no medicine” and send you to the drug shop.’ (District health manager, Rufiji)

Overall, it is clear from these perspectives that WAJA are highly regarded by stakeholders, but weak logistics and supervision systems and poor human resource coordination challenge the feasibility of coherently integrating the WAJA into the district health system.

How do health system and community stakeholders perceive the shifting of tasks from clinics to WAJA? WAJA were perceived by community members and facility-based providers as health workers who improve the quality of care. A WAJA facility supervisor explains: You find after their children receive [WAJA child health/IMCI] service [parents] acknowledge it is very good and they are saying nowadays that when you go to hospital the doctor does not examine the child thoroughly, but when you go to [WAJA] they examine the babies thoroughly. (FDG, WAJA Health Facility Supervisors, Rufiji)

Participants remarked on the contextual appropriateness of WAJA services:

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Regarding our young man WAJA, he is the link [between] the patient and service providers. We service providers, I think because of too much work, we are not that close to patients as how WAJA is close to patients because has been opportunity to do home visits. This has made [the household] his friend so in short WAJA I see has many responsibilities even more than I; I stay here waiting for patients to come. (WAJA, Facility Supervisor, Kilombero)

Health worker and manager perceptions of the impact of WAJA on the overall continuum of care were mixed:

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On my side [the influx of clients] was reduced, especially children but those whom I get are severe. Now I get worried that there at the village [WAJA] treated severe malaria with Alu as a result now when they come it becomes more severe. Now they come to me when they are serious, but patients are not many as used to be before WAJA they are not that much, especially children. (FGD, WAJA Health Facility Supervisors, Rufiji)

Community stakeholders reported that the WAJA integrated service package addresses priorities and concerns: We saw that malaria requires education and if possible needs more improvement, For this we have this new program [WAJA] … If you will look on the side of HIV, these are the same people and are people who can be instructed by [WAJA]. (Village Chairman, Kilombero)

However, some respondents expressed concerns about the WAJA maternal health and family planning components: Frankly the pregnant mothers and children board the same bus, so both two need to be prioritized because the mother is carrying the baby. You cannot attend a child and forget the mother, if you forget the mother she will face more problems and she will forget the child. (FGD, Men, Rufiji)

Women also remarked: Some like to use injection more than pills so that she can hide so that the husband should not know. Because she will have to swallow [pills] everyday, the husband can know. This is a challenge. Due to the guidelines for WAJA they cannot get to that level to give the injection so they will continue to use pills. (FGD, Women, Kilombero)

Some respondents initially perceived WAJA as a replacement for facility-based services. But this perception has changed over time: When we started as WAJA, it was difficult for the community to accept us and to understand what our responsibilities are. Since we were out for the studies for almost nine months, they thought we are doctors, but after educating them and after seeing us moving here and there in the community they came to realize that we are just helping doctors in providing health services at household level, our main work is to dispense some drugs of less serious diseases at home. (FGD, WAJA, Rufiji)

Both women and men remarked that the programme was appropriately adapted to rural life and prevailing demands on families. Men held this perspective: A child might be sick [when parent is working on the farm], but what might happen is that the parent is not there, and then this is the case and children become worse even. But our WAJA is called to observe the child and advise that the child according to condition is supposed to be sent to the hospital, give instruction according to the condition. (FGD, Men, Kilombero)

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In general, findings indicate that beneficiaries appreciate the WAJAs’ integrated service package, but express disappointment that WAJA cannot provide more interventions than Connect permits. Health workers acknowledge that WAJA alleviate their workload. However, they are concerned that clients wait at home for WAJA services in lieu of attending facilities as appropriate.

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Does WAJA implementation sustain community participation in the programme? Responses suggest that this process engendered community support. Participants commonly referred to WAJA as ‘WAJA, watoto wetu’ (WAJA, our children), ‘wanangu’ (my offspring). Similarly, their community supervisors are referred to as ‘Mama WAJA’ (Mother of WAJA), reflecting how WAJA are embedded in wider kinship relations within their community. Though varying across villages, challenges to community ownership of the WAJA programme were evident, particularly concerning WAJA’s child-focused service package: [WAJA] don’t have the idea on how to help if it is me that is suffering. I would like to see WAJA being trained more so that they can even help us more rather than going to the health facilities, for sure there is nothing we get there. (FGD, Men, Kilombero)

Village governance and leadership affect WAJA performance. In some villages, when WAJA conduct their village visits, local politicians and hamlet leaders support them. ‘We meet an influential person in the village, he assists us by going around in the community to identify the households and introduce us to the family’ (FGD, WAJA, Rufiji). In other instances, participants lamented governance problems: The response of the village government is not so good. There was a time we informed them on preparing cupboards for storing the medicine, nothing has been done, three months have passed. Another issue is on environmental cleanliness After educating the community of the whole issue of sanitation, we no longer have the ability to summon someone and hold them accountable, but if we cooperate with the village government, I believe that this issue would have been solved. (IDI, WAJA, Rufiji)

WAJA are salaried as functionaries of the local government, unlike members of Village Councils, nearly all of whom are unpaid. This attracted criticism from village authorities: ‘[The WAJA] cooperate well with me. Still, salary should be given [to us]’ (Village Chairman, Rufiji). Supervisors conveyed a sense demoralisation: ‘We fail to do our job because you don’t have food, no allowance, and even the WAJA he maybe will not listen to you as you are only a volunteer while that one is getting paid’ (FGD, Village Supervisor, Rufiji). Poor coordination of incentive schemes undermined village government’s commitment to managing WAJA operations during the early stages of the programme. WAVI are volunteers recruited in the 1990s to implement the UNICEF-sponsored Child Survival, Development and Protection Programme (CSDP). WAVI were recruited but not accorded official training. For example, in some localities they were trained for as long as six months, while in other localities, training was limited to two months. In the final stages of the programme, training was limited to just a few days. The CSPD services package integrated preventive and promotional care for children. Though the CSDP has ended, some WAVI remain active in villages where WAJA were deployed. Connect’s WAJA frequently draw upon their support that: ‘WAJA and WAVI have differed in

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their roles, however WAJA have more responsibilities. WAVI is responsible in examining children, and they provide immunisation education. My other responsibility, together with the provision of education, is treatment’ (WAJA, Kilombero). WAJA, faced with a complex role, are aided by WAVI. As one WAVI noted: ‘So as we go to educate them [the clients] can wish to take some information from me, before I take her to [WAJA]’ (WAVI, Rufiji). Stakeholder involvement in promoting maternal health is complex. According to WAJA: ‘In the beginning, there were beliefs associated with delivering with traditional birth attendants. After we started doing the house-to-house visits we told people about what we do, we talked to the TBAs and now they are cooperating with us’ (FGD, WAJA, Kilombero). Whereas WAJA have been effective in addressing traditional birthing practices, the spousal opposition to family planning is a continuing challenge: Men give us big challenges because they are completely against use of family planning by their wives. As a WAJA, it is my responsibility to educate this man or the household until they support the woman who wants family planning, but I have to confess that this is a big challenge as most men are completely against family planning methods. (FGD, WAJA, Kilombero)

In summary, a bond has emerged between WAJA, their communities, and stakeholders. However, in the social and political environment structural constraints are embedded which compromise how communities manage and participate in primary health care.

Discussion A limitation of this analysis concerns the timing of data collection, which was limited to the first 14 months of the programme. Therefore, the outcomes examined in the paper – feasibility, acceptability, and participation – are early stage outcomes. Subsequent analysis will address long-term reactions of stakeholders to WAJA deployment. Also, the use of community representatives to recruit study participants may have generated biases in the feedback. These representatives, for example, may have selected participants that would provide favourable reactions, feeling obligated to please a project that is delivering resources to their communities.

Integration of WAJA into the wider health system Connect evidence is consistent with examples from many CHW initiatives in Tanzania, and other countries in the region, which have encountered organisational and sustainability problems. Since the inception of these programmes in the 1970s and 1980s, governments have often lacked capabilities to implement essential components of integrated care systems. This challenged large-scale training, supervisory system development, resource management for remunerating and incentivising cadres, pharmaceutical supplies, and logistical support (Banek et al., 2014; Gilson et al., 1989). Research from other countries has advocated the strengthening of government coordination of primary health-care interventions, including supplying functional health centres, training health workers at facilities, and actively involving CHW, as an essential short-term

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strategy for CHW programming (Kouam et al., 2014). Addressing these issues in Tanzania must be central to the national CHW scale-up. Salient among these is the weak logistics system, since WAJA credibility and motivation are directly related to the availability of essential supplies.

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Stakeholders’ perception of task shifting and WAJA Results suggest that stakeholders would prefer a systems approach to WAJA programming in which clinicians, as relative specialists in curative care, are on call when WAJA encounter conditions that lie beyond their preventive counselling, education, and curative capabilities. Respondents favourably received those WAJA who not only counsel and educate, but also identify illnesses, provide treatment for basic cases, and refer complicated cases to clinics. WAJA credibility is grounded in this integrated aspect of their work package, but this credibility waned when they lacked supplies required for the provision of essential capabilities (Callaghan-Koru et al., 2012). Clients interviewed believed that Connect placed an inadequate emphasis on maternal health services, and expressed a demand for task shifting more interventions with WAJA. Women, in particular, lament that WAJA cannot provide a wider mix of family planning methods, namely the most popular method, Depo Provera (Demographic and Health Survey, 2010). There is evidence from other settings in the region which shows that this has can be effective (Ejembi, Norick, Starrs, & Thapa, 2013; Malarcher et al., 2011). Other task-sharing studies report high levels of satisfaction with the practice, provided that implementation expands the workforce, ensures adequate training for all those involved, and secures access to medications (Mendenhall et al., 2014). Such conclusions are relevant to Connect. Client dissatisfaction with WAJA is often grounded in frustration with the health system. Health-care worker acceptance of WAJA is tempered by concerns that they inadvertently divert clients from utilising clinics. Responding to the demand for task sharing with CHW should address organisational challenges confronting the provision of primary health care as an integrated system. Community participation in the WAJA programme The question has been raised whether CHW empower or oppress as a result of the existing socio-economic and political circumstances (Werner, 1981). Seconding the WAJA intervention to local management structures was pursued under the assumption that this would improve the system’s accountability to communities, but this depended on structures for managing the WAJA as part of a broader primary health-care programme. Uneven maintenance of these structures (e.g. Village Councils and Health Committees) rendered the crystallisation of community buy-in and appreciation into long-term participation and governance of communities a challenge for Connect. There is a lack of community voice in articulating what services the WAJA provide, their standing and remuneration vis-à-vis other village officials. CHW are most effective when they elicit the participation of the community and facilitate change at this level (Bhattacharyya, Winch, LeBan, & Tien, 2001; Gryboski, Yinger, Dios, Worley, & Fikree, 2006), yet programmes guided by technical experts and policy-makers are not always in synchrony with community institutions. As a corollary, community members may see WAJA as

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extensions of health services from clinics, more accountable to the formal health system than to community initiative. Frameworks for participatory learning that appear in the health literature are embraced by Tanzanian policies (Rifkin, 1996). Nevertheless, the official process for implementing CHW programmes is often guided by bureaucratic directives and constraints (Frumence, Nyamhanga, Mwangu, & Hurtig, 2014). Since programme success is enhanced if CHW have community respect and support, intervention planning should elicit community opinion about what CHW should do and who best contributes to sustaining the programme. Health, particularly in marginalised groups, is affected by the social and organisational environment. Risk factors inherent in those structures can impair capacities and relationships that enable good health, including those which involve CHW. WAJA were deployed to address socio-environmental causes of ill health. Yet, their relative youth and inexperience within power hierarchies limited their effectiveness. Capacity-building towards giving vulnerable groups more control over decisions succeeds when communities recognise that they can collectively change their circumstances. CHW programming can address this need if enabling structures are put in place that define who constitutes the community, who is supporting CHW, and who is accountable to whom given the social and political context (Howard-Grabman et al., 2007). Insights on the roles of WAVI suggest that minimally trained volunteer workers contribute to WAJA performance. WAJA and WAVI reportedly harmonised their work activities, although tensions sometimes arose regarding remuneration. Similarly, insights on health-care and pharmacy workers illuminate reflect the need for improving the coordination and responsiveness of the health system to community needs, as WAJA articulate and channel them upwards. Implementation approaches for strengthening the accountability of health systems and mobilising community support should thus be synergistic in order to achieve stronger continuum of care.

Conclusion Connect is contributing to policy on a new national cadre of CHW in Tanzania. Results from this analysis attest to the demand for the WAJA model, and widespread perceptions of its acceptability and added value. Yet, respondents draw attention to the essential need to develop health system and community support systems, suggesting that CHW programming should be pursued through an integrated primary health-care systems approach that coordinates and builds upon the roles of community members, CHW, clinicians, and managers of district health systems. Coordinating sustained support from the health system and communities will be essential for affirming the policy assumptions about CHW and also, perhaps, the trial hypothesis of Connect, that it will reduce childhood mortality. Logistics and supervisory systems development, primary health-care workforce integration, local leadership, governance, and community support are all critical for the effective introduction of CHW in Tanzania.

Acknowledgements The authors of this publication have no financial interests or benefits arising from the application of the research presented in this publication.

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Funding This work was supported by the African Health Initiative of the Doris Duke Charitable Foundation [grant number DDCF2009058a] and Comic Relief UK [grant number 112259].

Disclosure statement No potential conflict of interest was reported by the authors.

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An exploration of the feasibility, acceptability, and effectiveness of professional, multitasked community health workers in Tanzania.

Despite four decades of global experience with community-based primary health care, the strategic details of community health worker (CHW) recruitment...
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