Improving access to child health services at the community level in Zambia: A country case study on progress in child survival, 2000-2013

Reductions in under-five mortality in Africa have not been sufficient to meet the Millennium Development Goal #4 (MDG#4) of reducing under-five mortality by two-thirds by 2015. Nevertheless, 12 African countries have met MDG#4. We undertook a four country study to examine barriers and facilitators of child survival prior to 2015, seeking to better understand variability in success across countries. The current analysis presents indicator, national document, and qualitative data from key informants and community women describing the factors that have enabled Zambia to successfully reduce under-five mortality over the last 15 years and achieve MDG#4. Results identified a Zambian national commitment to ongoing reform of national health strategic plans and efforts to ensure universal access to effective maternal, neonatal and child health (MNCH) interventions, creating an environment that has promoted child health. Zambia has also focused on bringing health services as close to the family as possible through specific community health strategies. This includes actively involving community health workers to provide health education, basic MNCH services, and linking women to health facilities, while supplementing community and health facility work with twice-yearly Child Health Weeks. External partners have contributed greatly to Zambia’s MNCH services, and their relationships with the government are generally positive. As government funding increases to sustain MNCH services, national health strategies/plans are being used to specify how partners can fill gaps in resources. Zambia’s continuing MNCH challenges include basic transportation, access-to-care, workforce shortages, and financing limitations. We highlight policies, programs, and implementation that facilitated reductions in under-five mortality in Zambia. These findings may inform how other countries in the African Region can increase progress in child survival in the post-MDG period. The period of interest for the parent study on child survival in Africa and this case study was 2000–2013. As described below, indicator data were obtained for years closest to 2000 and 2013, while the review of national policies, key informant interviews, and focus groups with community women was conducted in 2013 and focused on more recent years. Data were obtained on the core indicators monitored by Countdown to 2015. Most data were obtained from the World Bank Data Catalogue (World Bank), which is a repository of national, regional and global indicator data compiled from officially recognized sources, including national Demographic and Health Surveys (DHS) and other national surveys. Data for indicators not readily available from the World Bank Data Catalogue were obtained directly from the 2001/2002 Zambia DHS (Central Statistical Office [CSO] et al., 1997) or the 2013/2014 Zambia DHS (CSO et al., 2014). Given the scope of the larger study within which this case-study is nested and recognizing that data are not always available for the exact year of interest, indicator data were obtained that most closely corresponded to the beginning of the study period in 2000 (range 1998–2003) and end of the study period in 2013 (range 2009–2014). Based on a review of the peer-reviewed literature and published global strategies related to child survival, an information abstraction guide was developed to guide the document procurement and review process for this study (Table 1). Policies and strategies pertaining to overall national health, MNCH, and those from other sectors related to MNCH (e.g., education, water and sanitation, and agriculture and nutrition) were obtained from the WHO African Region office, the WHO country focal points for Zambia and Zambia’s Ministry of Community Development, Mother and Child Health (MCDMCH). These primary documents were reviewed according to the abstraction guide and any additional documents referenced and deemed important to complete the review were obtained from WHO or MCDMCH. The final list of reviewed documents is in Supplementary Table S1. Content areas and key questions and themes related to child survival explored during the review of national health policies and strategies, key informant interview and focus groups with community women The abstraction guide was used to standardize abstraction and summarization of content across documents. Each document was reviewed multiple times by the same author (CAH) and as needed by a second (AMK or MAB), and information was recorded as outlined in the abstraction guide. In order to avoid biased interpretation of the information documented, the abstracted information was reported as it was stated in the original source, avoiding overstating or minimizing the original information or adding commentary not contained in the source. Because important differences in MNCH often exist between urban and rural areas, participants for the qualitative study were included from both urban and rural areas. Southern Province was selected as the study region because its under-five mortality annual rate of reduction (ARR) was comparable to the national ARR based on Zambia DHS data from 1996 and 2007 (CSO et al., 1997, 2009). Livingstone (urban site) and Kazungula (rural site) were selected as the two study sites. Data were obtained from semi-structured, key informant interviews with officials in the MCDMCH (including some national-level officials in Lusaka), donor organizations (all in Lusaka), community-based organizations (CBO) involved in MNCH, and health care workers (HCW). Data were also obtained from four focus group discussions (two in Livingstone, two in Kazungula) with women who have had experience accessing MNCH services. Interviews and focus groups were conducted by one of the authors (MM) and two research assistants between August 20 and December 18, 2013. All participants, whether key informants or focus group women, were eligible for the study if they met the following criteria: (1) being 18 years of age or older, (2) having adequate knowledge or experiences related to childhood survival specified for each participant group below, (3) speaking English, Tonga or Nyanja and (4) being able to provide written or verbal informed consent. Specific inclusion criteria for each key informant group included the following: national or provincial-level officials working in government-level health care system administration, policy-making, program development, leadership, or any aspect of MNCH (MCDMCH officials); directors, managers or other leaders of entities providing financial or other aid for MNCH services, or international or national organizations focusing on MNCH or with MNCH as one component of their mission (Donor organizations); directors, leaders, or managers working for a CBO involved in or providing referrals to MNCH services; and professionally trained physicians, nurses, clinical officers, or other health-related staff working in a health facility providing MNCH care (HCWs). Similar numbers of participants from each key informant group were enrolled, and a range of ages, work experiences and positions/roles within each group was sought. Additionally, efforts were made to balance the number of urban and rural participants among the HCWs and CBO workers. Lists of potential key informants from each group were developed by the in-country research team with assistance, as needed, from the WHO National Programme Officer for Child and Adolescent Health and the MCDMCH Deputy Director for Child Health and Nutrition. A letter signed by an official from the MCDMCH was sent to each potential key informant participants informing them of the purpose of the study, risks and benefits of participation, and describing the interview process. These were followed-up with a phone call or email from the research team to set up a meeting time for those interested in participating. Among the MCDMCH (n = 6), CBO (n = 10) and HCW (n = 9) key informants, an equal number of men and women participated, while the donor organization participants (n = 6) were entirely female. Median ages were similar for the MCDMCH (47 years; Inter-quartile range [IQR]: 46–49), donor (44; 41–50), and CBO (46; 42–57) participants; HCWs were generally younger (41; 37–43). MCDMCH participants had spent a median of 21 years working in the Ministry (IQR: 16–25) compared to shorter durations spent with their respective organizations for donor (5 years; IQR: 4–12), CBO (7; 5–12), and HCW (4–14) participants. Community women were recruited to participate in focus groups using informational flyers or advertisements. As with the key informants, a balance was sought in the level of education and the participants with live and deceased children, as well as a diversity of experiences and opinions regarding MNCH. Written informed consent was obtained from all participants who were enrolled. Rural (n = 21) and urban (n = 18) focus group participants had similar demographic and health characteristics except that rural women more often experienced the death of a child under 5 years old (33 vs 6%) (Table 2). Characteristics of female focus group participants in Zambia We developed interview guides for key informants and discussion guides for focus groups with community women. We then pilot tested them through cognitive interviewing, (Collins 2003) and revised as needed. The guides focus on barriers to and facilitators for improving child survival areas related to MNCH, corresponding to the structure for the review of national health policies and strategies (Table 1). Not all topics were appropriate for each key informant group, but each topic was asked of at least two of the four groups. While participants could discuss the entire period from 2000 forward, most participants recalled more recent information and experiences. Key informant interviews were conducted in English by one research assistant using the appropriate interview guide and were audio recorded. The focus group discussions were conducted in Tonga or Nyanja and also audio recorded. Two research assistants were present at each focus group to facilitate discussion and note-taking. Following completion of the interviews and focus group discussions, audio recordings were transcribed by the research assistants, translated into English as needed, and field notes incorporated into the transcript. Transcripts were coded and analysed using the qualitative software Atlas.ti (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany). Deductive themes were determined a priori based on interview guides and key topics of interest based on literature review. Additional themes were also identified upon review of the transcripts. Text was coded and reviewed for patterns of consistency, variation, relationships between themes and exemplary cases or quotations (Schensul 1993; Nastasi and Schensul 2005). Ethical approval for the project was obtained from Vanderbilt University Medical Center and ERES Converge (Zambia) Institutional Review Boards.