Community health workers programme in Luanda, Angola: An evaluation of the implementation process

Background: The Community Health Workers (CHWs) Programme was launched in Luanda, Angola, in 2007 as an initiative of the provincial government. The aim of this study was to assess its implementation process. Methods: This is a case study with documental analysis, CHWs reports data, individual interviews and focus groups. Results: Until June 2009, the programme had placed in the community 2,548 trained CHWs, providing potential coverage for 261,357 families. Analysis of qualitative data suggested an association of CHWs with improvements in maternal and child access to health care, as well as an increase in the demand for health services, generating further need to improve service capacity. Nevertheless, critical points for programme sustainability were identified. Conclusions: For continuity and scaling up, the programme needs medium- and long-term technical, political and financial support. The results of this study may be useful in strengthening and reformulating the planning of the CHWs programme in Luanda and in Angola. Moreover, the lessons learned with this experience can also provide insight for the development of CHWs programmes in other parts of the world. By means of cooperation, Brazil has supported the implementation of this CHWs programme and can potentially contribute to its improvement. The present study is part of a broader cooperation project between Brazil and Angola with the objective of supporting the development of PHC in Angola. The fieldwork took place in Luanda over 2 missions, lasting 2 to 3 weeks each, in the period between May 2008 and June 2009. We used the case study method, with the following as sources of evidence: legal and technical documents, records of evaluation sheets from CHWs, semi-structured interviews, and focus groups. The study of these sources made it possible to analyze the implementation of PACS-Luanda, evaluating provision indicators (human resources, structural and organizational aspects, work materials) in relation to their adequacy (the extent to which the programme objectives were met) [14, 15]. The different types of respondents in the individual interviews and focus groups (provincial managers, district coordinators for the CHWs, and CHWs), allowed us to investigate and understand different perspectives of the phenomenon being studied. For documental analysis, we used documents on health policies in Angola and Luanda, especially those related to PHC, in addition to the legal documents. An additional file lists all the documents examined in this analysis (see Additional file 1). For individual interviews and focus groups, we developed a script for each type of respondent. The focus group technique was applied to the CHWs, for the possibility of obtaining their testimony given the social interaction among participants [16]. Participants were selected by convenience, based on a call from municipal coordinators. Individual interviews were conducted with two provincial level managers, the UNICEF representative responsible for supporting the PACS-Luanda (considered as a provincial manager) and six district coordinators (one from each district). The six focus groups (one per district) gathered forty-eight CHWs in total (average of eight per group). The interviews and focus groups were all conducted in Portuguese by the main researcher (CG), who is Brazilian and a native Portuguese speaker. All focus groups were co-facilitated by a second researcher, who was in charge of recording and taking notes. The interviews lasted on average 40 minutes, while the focus groups lasted approximately 1 hour and 20 minutes each. All interviews and focus groups were recorded and later transcribed. Interviews and focus groups broadly covered the following areas: objectives of the CHWs programme, view of the programme’s progress in the reality of the districts where it was implemented, positive aspects, critical points and difficulties of the programme (or of the CHWs’ work), and perspectives about the continuity or suggestions to improve the programme. Additional aspects covered were: assessment of the programme’s progress as a health policy in Luanda (in interviews to managers); description of the coordinator’s work and feelings about it, view of the CHWs’ work, and description of data collection procedures by CHWs (in interviews to coordinators); and description of the CHWs’ daily work, pointing out positive aspects and limitations (focus groups with CHWs). All records made by CHWs, available from December 2007 to December 2009, with data on the number of trained CHWs and families they followed up during the period, were entered. Documental analysis was used to describe the implementation of the programme and to make comparisons between observed events and what was originally planned. Records from CHWs were entered in an Excel spreadsheet (Microsoft, Redmond, WA, USA) for descriptive analysis over time through frequencies and proportions. For interviews and focus groups, content analysis was performed [17, 18]. Building on the analysis axes, previously assembled for field research (such as the objectives of the PACS, positive results and difficulties), the collected material enabled the creation of categories and subcategories. This was followed by a review of discursive passages allocated in each category in order to correct inconsistencies [18]. Patterns of convergence and divergence were identified among different types of respondents, seeking to characterize their specificities [17, 18]. To assist in the organization of data, we used a software for qualitative data analysis (MAXqDA) [19]. This study was approved by the Ethics Committee of the Federal University of Rio Grande do Sul (UFRGS) and authorized by the PDH in Luanda. All participants read and signed an informed consent form.