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Table 4 Tanzania Connect Partnership project: Successes, Challenges, and Adaptations

From: The Tanzania Connect Project: a cluster-randomized trial of the child survival impact of adding paid community health workers to an existing facility-focused health system

Successes
Development of a curriculum that creates the appropriate competencies
The results from the training showed that the recruits, with the specified qualifications, could be trained to properly apply the principles of community IMCI and manage uncomplicated cases of diarrhoea, pneumonia and malaria as well as provide a broader package of reproductive child health services.
Deployment and support of a new community-based cadre to provide RCH services
CHA have largely been able to provide the package of care in the real world context of their villages. Reports show that acceptability of the CHA and their services among a variety of stakeholders, including communities, health workers and district management, has been high. In addition, the supports designed for the CHA appear to have facilitated their work.
Collaboration and ownership by national, district and local government
At national level, processes are underway to define a new cadre of community health worker and Connect operational evidence has played an important role in these processes. In addition, the district and village authorities have been instrumental in facilitating the CHA introduction and mediating any problems or challenges encountered. The engagement for the referral planning has provided a solid foundation for ensuring the relevance of strategies to local conditions.
Challenges
Chronic system shortages of medicines and supplies
There are nationwide supply chain challenges which include frequent stockouts of some essential medicines for RCH. As a result, the project has had to use vertical procurement mechanisms for the CHA. These stockouts also compromise the CHAs ability to provide added value to the system and to facilitate effective referrals and will affect the system’s ability to respond to emergency cases.
Effective supervision at the community level
The decision not to pay village supervisors to support the CHA, who are paid, has produced tensions that may have undermined this relationship. Village supervisors report both that they are doing more than requested and that they need more tools and motivation to do this work.
Balancing prevention, treatment and promotion services
Early findings reflect a widespread struggle among CHA to achieve a balance between the treatment and educational or promotional aspects of their role. This may reflect demand in addition to other factors as communities’ prioritized the provision of medicines more highly than other services.
Adaptations
Coverage of CHA
Based on early implementation experience, areas served by one CHA were increased to two as many of these areas are large geographically even if populations are small.
Adaptations to the CHA kit
While the basic contents of the CHA kit were found to be largely appropriate, some medicines and supplies were later added based on feedback, for instance for first aid (e.g. iodine) and rapid diagnostic kits for malaria.
Extension of referral planning process
While it was expected that the planning process could be completed rapidly, while underway, additional stages were added to ensure that groups typically excluded from these processes, such as local transport drivers, were able to have a voice.