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Background: Global concerns regarding effective response strategies to the COVID-19 pandemic arose amid the swift spread of the virus to low- and middle-income country (LMIC) settings. Although LMICs instituted several measures to mitigate spread of the virus in low resource settings, including task shifting certain demand and supply functions to community actors such as community health workers (CHWs), there remains a lack of synthesized evidence on these experiences and lessons. This scoping review sought to synthesize evidence regarding the roles and challenges faced by CHWs during the fight against COVID-19, along with strategies to address these challenges.

Methodology: We systematically searched several major electronic databases including PubMed, HINARI, Cochrane Library (Reviews and Trials), Science Direct and Google Scholar for relevant literature. The search strategy was designed to capture literature published in LMICs on CHWs roles during COVID-19 period spanning 2019–2023. Two researchers were responsible for retrieving these studies, and critically reviewed them in accordance with Arksey and O’Malley scoping review approach. In total, 22 articles were included and analysed using Clarke and Braun thematic analysis in NVivo 12 Pro Software.

Results: Community health workers (CHWs) played a vital role during the COVID-19 pandemic. They engaged in health promotion and education, conducted surveillance and contact tracing, supported quarantine efforts, and maintained essential primary health services. They also facilitated referrals, advocated for clients and communities, and contributed to vaccination planning and coordination, including tracking and follow-up. However, CHWs faced significant challenges, including a lack of supplies, inadequate infection prevention and control measures, and stigma from community members. Additionally, they encountered limited supportive policies, insufficient remuneration and incentives. To enhance CHWs’ performance, regular training on preventive measures is essential. Utilizing digital technology, such as mobile health, can be beneficial. Establishing collaborative groups through messaging platforms and prioritizing access to COVID-19 vaccines are important steps. Additionally, delivering wellness programs and providing quality protective equipment for CHWs are crucial for their effectiveness.

Conclusion: The study found that CHWs are vital actors within the health system during global pandemics like COVID-19. This entails the need for increased support and investment to better integrate CHWs into health systems during such crises, which could ultimately contribute to sustaining the credibility of CHWs programs and foster more inclusive community health systems (CHSs).

Background: In many low-and middle-income countries, tobacco smoking andharmful alcohol consumption are major public health threats that are inadequatelyaddressed at the policy level. For example, efforts to formulate a comprehensivetobacco control policy have been on going in Zambia for close to 12 years, but thecountry has still not yet been able to finalise one. While Zambia adopted an alcoholpolicy in 2018, its implementation remains a huge challenge. This thesis sought toenhance understanding of the context and the collaborative dynamics in the Zambiatobacco control and alcohol policy processes. In particular, it aimed (i) to determinethe extent and sociodemographic determinants of tobacco smoking and harmfulalcohol consumption (Sub-study 1); (ii) to explore and explain the role of principledengagement and shared motivation in the delayed tobacco control policy (Sub-study2); and (iii) to unpack factors that shaped the capacity for joint action in theimplementation of the alcohol policy (Sub-study 3).

Methods: This was an embedded mixed-methods study that comprised a acrosssectionalstudy based on the Word Health Organization STEPs population-basedsurvey of 4302 individuals (Sub-study 1) and two policy case studies – the tobaccocontrol policy development (Sub-study 2) and the alcohol policy implementation(Sub-study 3). Sub-study 2 used key informant interviews data collected from 27tobacco control policy stakeholders across several government sectors, civil society,and an international organisation. The data was supplemented with a documentreview of tobacco laws and policies in Zambia. Regarding Sub-study 3, 25 keyinformant interviews were conducted with members of the National Alcohol PolicyImplementation Coordination Committee. The quantitative data were analysedusing log binomial regression while thematic analysis was applied to the interviewdata.

Results: For the context, Sub-study 1 showed substantial disparities in daily tobaccosmoking and binge drinking between men and women. There was a higherprevalence of smoking in men, older adults, and those with the lowest educationlevel, while binge drinking was more prevalent in men and urban residents. Substudies2 and 3 revealed several system level factors that affected the collaborationin the tobacco control policy process, including interference from the tobaccoindustry, contradictory laws that incentivise tobacco production and weakenforcement of subsidiary tobacco control laws. Further, the systemic issuesaffecting collaboration in implementation of the alcohol policy comprised theframing of alcohol as an economic issue, the weak regulation of illicit alcoholvproduction and the sociocultural acceptance of harmful alcohol consumptionbehaviours. According to Sub-study 2, the collaborative dynamics of principledengagement and shared motivation in the tobacco control policy process have beenconstrained by ineffective communication, mistrust, limited evidence, the absenceof community advocacy and the lack of authority among sector representatives. Substudy3 revealed that the alcohol policy is generally recognised as a framework forstakeholder action targeting the control of harmful alcohol consumption. However,weak coordination and resource challenges among implementing agencies haveundermined their capacity for joint action, ultimately impeding the implementationof this policy.

Conclusion: The higher prevalence of tobacco smoking and binge drinking amongsub-groups such as men, older adults, those with the lowest education level andurban residents calls for targeted strategies in collaborative efforts to addresstobacco and alcohol. Several policy and legal issues affect the development of thetobacco control policy, while the collaborative dynamics are fraught with challengesthat threaten critical collaborative outcomes such as trust, commitment andlegitimacy. Thus, embracing practices that seek to foment trust, understanding, andlegitimacy among key government sectors may go a long way in acceleratingcollaboration in the tobacco control policy process. Furthermore, enhancing thecollaborative efforts to implement the alcohol policy will require strengthening thecapacity for joint action by overcoming coordination and resource challenges amongimplementing agencies.

Introduction: Many low-and middle-income countries, including Zambia experience a huge deficit of human resource for health, which affects the delivery of primary health care services such as maternal and child health (MCH), nutrition, HIV and gender-based services. The Clinton Health Access Initiative in collaboration with the Zambian Ministry of Health implemented a community health systems (CHS) strengthening project to enhance the capacity of community health assistants (CHA) to provide MCH services from 2019 to 2021. The project activities included capacity building in supervision, provision of financial incentives and logistics. This study explores how these interventions strengthened the role of the CHAs in delivering MCH services.

Methodology: This was a qualitative study consisting of 189 KIIs and IDIs as well as 20 FGDs conducted in all the 10 provinces of Zambia with the CHAs, and their supervisors, health workers, neighbourhood health committees and community members. Data were analysed using thematic analysis.

Results: The CHS strengthening interventions including provision of training manuals, streamlined recruitment and deployment policies, capacity building of CHA supervisors, provision of transport and monthly remuneration contributed to improved delivery and acceptability of MCH services. Further, the leveraging of community networks, linkages and partnerships when delivering these services, including the traditional and religious leaders contributed to improved coverage and acceptability of MCH services. Meanwhile, health systems barriers such as limited supplies in some health facilities, shortage of health workers, persistent transportation challenges and failure to fully abide by the CHA recruitment and selection criteria affected delivery and acceptability of MCH services.

Conclusion: This study builds on existing evidence on the importance of building a stronger community–based primary health care to effectively address maternal and child health related issues. We emphasize the need to integrate strategies such as provision of training manuals, enhanced recruitment and deployment policies, capacity building of supervisors, provision of transport and remuneration within the CHA program to enhance the provision and acceptability of health services.

Introduction: Community-based tuberculosis (TB) related interventions still face several implementation challenges that negatively affect attainment of overall national TB program goals. Yet, few studies investigate key implementation outcomes such as acceptability and adoption of these interventions. This study sought to explore the acceptability and adoption of health extension worker (HEW) driven community-based TB care (CBTC) program among community members in Gondar town, Northwest Ethiopia.

Methods: A qualitative case study design was employed, consisting of twenty-four in-depth interviews and three FGDs with a purposively selected sample of HEWs, HEWs’ supervisors, TB focal persons and community members. The study utilized deductive thematic analysis guided by Rogers' Diffusion of Innovation theory, which posits that the acceptability and adoption of interventions are influenced by attributes such as relative advantage, observability, compatibility and complexity.

Results: The program’s relative advantage including its perceived ability to promote TB prevention, early diagnosis, as well as the observed improved reporting mechanisms and treatment outcomes arising from HEWs visits facilitated its acceptability and adoption. The integration of community-based TB care into the health system and use of outreach activities to deliver TB information and services enhanced compatibility of the program with community health expectations. However, several factors hindered the delivery of the program, affecting its acceptability and adoption. These included limited career progression for HEWs, inadequate support from the district health office, an insufficient number of HEWs for the growing population, challenges in sustaining TB donor-funded programs, the impact of the civil war, the non-adherence to referral guidelines, and resource constraints.

Conclusion: To enhance the acceptability and adoption of CBTC, we recommended prioritizing community engagement, improving integration of the program in community health systems, addressing contextual challenges such as TB stigma, as well as enhancing program support for the health extension workers.

In Zambia, efforts to produce a tobacco control policy have stalled for over a decade, and the country is not yet close to developing one. Limited studies have explored the dynamics in this policy process and how they affect the attainment of policy goals and outcomes. This study explored how collaborative dynamics within tobacco control policy development shaped shared motivation among stakeholders in Zambia. The study used a qualitative case study design that adopted a collaborative governance lens, comprising an in-depth exploration of the tobacco control policy working group meetings and their internal collaborative dynamics. The integrative framework for collaborative governance, which identifies mutual trust, mutual understanding, internal legitimacy and shared commitment as key elements of shared motivation, was adapted for this study. Data were collected from 27 key informants and analysed using thematic analysis. Several collaborative dynamics thwarted mutual trust among tobacco control stakeholders, including concerns about associated loyalties, fear of a ban on tobacco production, silo-mentality and lack of comprehensive dialogue. All stakeholders agreed that the limited sharing of information on tobacco control and the lack of reliable local evidence on the tobacco burden hindered mutual understanding. Diverse factors hampered internal legitimacy, including sector representatives’ lack of authority and the perceived lack of contextualization of the proposed policy content. Acknowledgement of the need for multisectoral action, lack of political will from other sectors and limited local allocation of funds to the process were some of the factors that shaped shared commitment. To accelerate the development of tobacco control policies in Zambia and elsewhere, policymakers must adopt strategies founded on shared motivation that deliberately create opportunities for open discourse and respectful interactions, promote a cultural shift towards collaborative information sharing and address unequal power relations to enable shaping of appropriate tobacco control actions in respective sectors.

Background: Many low-and middle-income countries have adopted social health insurance schemes. However, the collection of contributions from the large informal sector of these economies poses a significant challenge. Employing an integrated system of contribution collection from all relevant institutions may be cost-effective. We used the integrative framework for collaborative governance, to explore and explain factors that may shape the governance of an integrated system for collecting contributions for social health insurance, pension, and taxes from the informal sector in Zambia.

Methods: We undertook a qualitative case study involving 25 key informants drawn from government ministries and institutions, cooperating partners, non-governmental organizations, and association representatives in the informal sector. Data were analyzed thematically using Emerson's integrative framework for collaborative governance.

Results: The main drivers of collaboration included a need for comprehensive policies and legislation to oversee the integrated system for contribution collection, prevent redundancy, reduce costs, and enhance organizational effectiveness. However, challenges such as leadership issues and coordination complexities were noted. Factors affecting principled engagement within the collaborative regime consisted of communication gaps, organizational structure disparities, and the adoption of appropriate strategies to engage the informal sector. Additionally, factors influencing shared motivation involved concerns about power dynamics, self-interests, trust issues, corruption, and a lack of common understanding of the informal sector.

Conclusion: This study sheds light on a multitude of factors that may shape collaborative governance of an integrated system for contribution collection for social health insurance, pension, and taxes from the informal sector, providing valuable insights for policymakers and implementers alike. Expanding social health insurance coverage to the large but often excluded informal sector will require leveraging factors identified in this study to enhance collaboration with pension and tax subsystems.

Introduction: Community participation is central to primary health care (PHC). However, there remains limited research on the practices of community involvement in PHC. This study aimed to inform the Zambian PHC agenda, by documenting key actors, their roles, interactions and available spaces or interfaces for engaging in community participation, as well as to identify the enabling conditions/mechanisms, and barriers underpinning community participation.

Methods: We used exploratory qualitative methods consisting semi-structured interviews with Community Health Assistants (CHAs) (n=10), healthcare workers (n=7) and traditional leaders (n=7). Additionally, focus group discussions were conducted with Neighbourhood Health Committees (NHCS) members (n=53) and community members (n=57). Data were analysed using thematic analysis.

Results: The CHAs, health workers and traditional leaders acted as the key intermediaries between health facilities and communities, driving co-production and social accountability processes. Traditional leaders and civil society organizations often served as initial catalysts of community participation, enabling the subsequent roles of the CHAs, while health centres and NHCs provided the spaces and platforms for community members to shape their involvement in participatory activities. Co-production entailed community contributions such as labour and participation in decision-making at health facilities. Social accountability took the form of suggestion boxes and informal feedback from traditional leaders. Several contextual barriers limited participation, including undefined roles for processes of community engagement, the lack of a comprehensive engagement strategy, and the exclusion of CHAs in health facility processes.

Conclusion: The CHAs and their roles, alongside those of other actors, were pivotal in supporting both co-production and social accountability processes. Strengthening community participation in primary health requires clearly defining the roles of various actors through the development of comprehensive community engagement strategies.

Background: Over the years, low-and middle-income countries have adopted several policy initiatives to strengthen community health systems as means to attain Universal Health Coverage (UHC). In this regard, Zambia passed a Community Health Strategy in 2017 that was later halted in 2019. This paper explores the processes that led to the halting and re-issuing of this strategy with the view of drawing lessons to inform the development of such strategies in Zambia and other similar settings.

Methods: We employed a qualitative case study comprising 20 semi-structured interviews with key stakeholders who had participated in either the development, halting, or re-issuing of the two strategies, respectively. These stakeholders represented the Ministry of Health, cooperating partners and other non-government organizations. Inductive thematic analysis approach was used for analysis.

Results: The major reasons for halting and re-issuing the community health strategy included the need to realign it with the national development framework such as the 7th National Development Plan, lack of policy ownership, political influence, and the need to streamline the coordination of community health interventions. The policy process inadequately addressed the key tenets of community health systems such as complexity, adaptation, resilience and engagement of community actors resulting in shortcomings in the policy content. Furthermore, the short implementation period, lack of dedicated staff, and inadequate engagement of stakeholders from other sectors threatened the sustainability of the re-issued strategy.

Conclusion: This study underscores the complexity of community health systems and highlights the challenges these complexities pose to health policymaking efforts. Countries that embark on health policymaking for community health systems must reflect on issues such as persistent fragmentation, which threaten the policy development process. It is crucial to ensure that these complexities are considered within similar policy engagement processes.

Background: Decentralized management approaches for multi-drug-resistant tuberculosis (MDR TB) have shown improved treatment outcomes in patients. However, challenges remain in the delivery of decentralized MDR TB services. Further, implementation strategies for effectively delivering the services in community health systems (CHSs) in low-resource settings have not been fully described, as most strategies are known and effective in high-income settings. Our research aimed to delineate the specific implementation strategies employed in managing MDR TB in Zambia.

Methods: Our qualitative case study involved 112 in-depth interviews with a diverse group of participants, including healthcare workers, community health workers, patients, caregivers, and health managers in nine districts. We categorized implementation strategies using the Expert Recommendations for Implementing Change (ERIC) compilation and later grouped them into three CHS lenses: programmatic, relational, and collective action.

Results: The programmatic lens comprised four implementation strategies: (1) changing infrastructure through refurbishing and expanding health facilities to accommodate management of MDR TB, (2) adapting and tailoring clinical and diagnostic services to the context through implementing tailored strategies, (3) training and educating health providers through ongoing training, and (4) using evaluative and iterative strategies to review program performance, which involved development and organization of quality monitoring systems, as well as audits. Relational lens strategies were (1) providing interactive assistance through offering local technical assistance in clinical expert committees and (2) providing support to clinicians through developing health worker and community health worker outreach teams. Finally, the main collective action lens strategy was engaging consumers; the discrete strategies were increasing demand using community networks and events and involving patients and family members.

Conclusion: This study builds on the ERIC implementation strategies by stressing the need to fully consider interrelations or embeddedness of CHS strategies during implementation processes. For example, to work effectively, the programmatic lens strategies need to be supported by strategies that promote meaningful community engagement (the relational lens) and should be attuned to strategies that promote community mobilization (collective action lens).

Background: Despite several global interventions, tuberculosis (TB) remains a leading cause of death affecting millions of people globally. Many TB patients either have no access to quality care or go undetected by national health systems. Several multilevel factors account for under-detection of persons with TB. This study sought to explore patient-related software, community and health systems software and hardware factors influencing time to notification of TB in Lusaka District, Zambia.

Methods: This was an exploratory qualitative case study that adopted a software and hardware lens of conceptualizing health systems. Data were collected from across three sites – urban and peri-urban areas: Chongwe, Kafue, and Lusaka – within Lusaka Province, Zambia. Sixteen key informants - TB corner nurses, community TB treatment supporters, and TB program managers - were interviewed. Six focus groups were held with TB patients. Data were analyzed using thematic analysis.

Results: The study identified factors influencing timely TB notification, categorized into software and hardware elements. Patient-related software elements, including TB knowledge and awareness, and health-seeking behavior, are crucial for prompt notification among TB patients. In the community health system, software elements like social stigma and undesirable community attitudes towards contact tracing, and hardware elements such as unbalanced schedules, excessive workload and limited capacity of community TB treatment supporters contribute to delayed TB notification. In the formal health system, software elements like negative attitudes of health providers towards TB patients and demotivation of TB staff, and hardware elements such as high diagnostics and transportation costs, outdated diagnostics in primary care facilities, and slow referral mechanisms, can also delay TB notification.

Conclusion: Delays in time to TB notification are influenced by a combination of software (attitudinal and behavioral) and hardware (resource-related) elements across TB patients, community health systems, community TB treatment supporters, health providers, and TB staff. Addressing these factors, particularly social stigma, negative attitudes, and resource constraints, is crucial to improving timely TB detection and treatment.