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Table 3 Zambia PHIT Implementation progress: success, challenges, adaptations

From: Protocol-driven primary care and community linkages to improve population health in rural Zambia: the Better Health Outcomes through Mentoring and Assessment (BHOMA) project

Successes
Local Ownership
The top-level leadership from each participating health district has been involved in the BHOMA project since its conception (including the application for initial funding) and each district has provided substantial human resources to program implementation.
Collaboration and partnership
We have successfully leveraged the substantial infrastructure and resources available through other programs sponsored by our group (e.g., support for HIV/AIDS care and treatment services) in the target districts. This has fostered trust and familiarity between project teams and regular Ministry of Health providers at the implementation sites.
Effective use of existing technology
Mobile phone coverage is now nearly 100% in Zambia. Our project was forward thinking in its adoption of this relatively low-cost technology for managing community health worker outreach activities.
Challenges
Staff turnover
Staff and volunteer attrition has required that the project frequently orient new hires and train replacements. Likewise, re-deployment of district level middle managers has required ongoing re-orientation meetings. This is critical to maintenance of quality of implementation and management of program activities, but comes at a fairly high cost.
Poor health facility infrastructure
Inadequate infrastructure, particularly storage space for the registry and filing rooms has been a perennial challenge. The sites often require substantial rehabilitations and at times investments that have exceeded available budget lines. For example, the project had to procure three 40 feet storage containers for three of the busy sites just to address filing, storage, and registry space.
Introducing a culture of accountability
Implementation of project activities required creation of an accountability culture that health workers - especially those providing direct patient care - are not accustomed to.
Adaptations
Monitoring CHW performance with a Lot Quality Assurance System (LQAS) methodology
To ensure the community health workers were actually performing the task we charged them with, we introduced LQAS sampling of households. Most CHWs are performing very well, but those who were not can now be identified and remediated.
Incentives for Traditional Birth Attendants (TBAs)
We noticed low rates of institutional delivery among women in rural areas and that many of these women were using the services of TBAs. We co-opted the TBAs into our community program, providing incentive payments for early referral of pregnant mothers to antenatal care, institutional delivery, and home, postnatal visitations. TBAs are now being monitored through the same common performance indicator system used for clinical care providers.
Neonatal follow up
During implementation it became apparent that the form used to capture a child’s sick visit was inadequate to guide the special care required for sick neonates. Therefore, the project went through an extensive consultative process to develop and implement a new neonatal form.