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

Tanzania pioneered many aspects of primary health care that were later endorsed at the 1978 conference on International Primary Health Care in Almaty (formerly Alma-Alta), Kazakhstan, through the Alma Ata Declaration. Plans in the early 1970s envisaged the rapid development of rural health centers and dispensaries providing primary health care services as well as launching of a Village Health Worker (VHW) Program [1]. VHWs were intended to extend services to villages, particularly due to the recognition that establishing dispensaries in every village was not immediately feasible [2]. While groundbreaking, these programs encountered challenges in ensuring uniform implementation nationwide and with retention and effectiveness related to provision of systemic support and adequate remuneration [3]. Revitalized in the 1980s with support from child-survival programs, early problems were partly addressed, but the programs were limited by their project-based nature, lack of formalized support systems, and reliance on local government mechanisms for remuneration. By the 1990s and early 2000s, despite the admirable continuing dedication of numerous VHW, many were working as assistants to facility-based providers and were largely maintained through periodic training by vertical health programs; the primary health care component of their work was largely unsupported [4, 5]. Due to the prolonged investment in rural health infrastructure, Tanzania now maintains one of the highest densities of health facilities amongst African countries. Health service organization follows the standard pyramid of dispensaries, health centers, and hospitals (Figure 1).

Connect focuses on the community level as well as linking the various levels through referral and feedback.

Household distance to the nearest health center is, on average, 10 kilometres (5 kilometres for dispensaries), but quality of care is often poor, with human resources operating at 32% of the required skilled workforce, insufficient medical equipment, and chronic shortages of medicines and supplies [6]. This is also undermined by weak referral systems that do not adequately identify and respond to acute conditions [7]. Consequently, availability, access, and utilization of essential maternal newborn child health (MNCH) services remain variable across the country.

While Tanzania has made substantial progress in the reduction of child mortality and is likely on track to reach MDG 4 [8], inequities remain with under-5 mortality rates ranging from 84 per 1,000 live births for the wealthiest quintile to 103 per 1,000 for the lowest quintile [8]. In addition, limited progress has been observed in reducing neonatal and maternal mortality, with neonatal mortality now comprising 30% of child mortality [9]. Care seeking for child illness was 57% for acute respiratory infection symptoms or fever and 47% for diarrhea, with declines in appropriate treatment of under-5 malaria and diarrhea in the last five years. Of children with fever symptoms who received anti-malarials within 24 hours, the rates varied from almost 50% for the wealthiest quintile to as low as 36.5% for the lowest quintile. Use of modern contraception (27%) has shown only modest gains in the last five years, with rates of approximately 35% among urban populations as compared to 25.5% among rural. For antenatal care, coverage is near universal at 98% for at least one antenatal care visit but drops significantly to 43% for four visits or more. Women also report late for the first visit, at a median of 5.4 months gestation. Only about half of Tanzanian women delivered in health facilities in 2010 [10]. Postnatal care remains low with 35% of women having received a postnatal check-up within six weeks after delivery.

Research has identified interventions that can reduce maternal, newborn, and child mortality as components of integrated primary care [11‐16]. Growing evidence shows that many of these interventions can be effectively delivered by community health workers or “lay health workers” at the community level [17, 18]. The Navrongo experiment in Northern Ghana provides an example of the mortality reductions that can be achieved in a relatively short time with the right package of interventions provided at community level [19, 20]. Effectiveness of community health workers in increasing preventive behaviors to improve newborn survival has been demonstrated in Asia [21]. The ability of community health workers to correctly diagnose and treat conditions such as malaria, acute respiratory infections, and diarrhea using integrated management of childhood illness (IMCI) has been established in a number of settings in Africa and Asia [22‐24]. Household visits by community health workers, including pregnancy monitoring and counseling, have also been shown to increase utilization of antenatal care, skilled delivery care, and immunization services [17, 25]. Additionally, it is expected that community health workers will have greater cultural competence than facility-based health worker cadres [7, 24].

Although the evidence-base is expanding for establishing the plausibility of community health worker impact, direct trial of the added value of paid community health workers remains the subject of discussion and debate. While there is widespread investment in community-based primary health care, all impact studies have been plausibility trials rather than randomized trials [5, 23, 26]. Moreover, the added value of a paid cadre is unknown in settings such as Tanzania where dispensaries are widespread and community access may not contribute to accessibility, quality, or acceptability of primary health care services. An extensive 2010 literature review of community health worker research revealed the diversity in the types of community health worker programs and substantial knowledge gaps [16]. There have been wide variations in training duration, content, and methods and inadequate attention to management, supervision, and career progression [17, 22, 27]. Additionally, availability of medicines, equipment, and transport are important determinants of effectiveness for service provision, which may also influence credibility among community members and motivation [17]. It is also hypothesized that community health worker programs could reduce system costs by shifting tasks to a cadre with shorter training and low remuneration as well as costs for the user by providing home-based care, but research on the cost-effectiveness is insufficient [18]. Motivation beyond recognition that financial remuneration is needed has also been under-researched [29].

A crucial component of any community health worker’s role is facilitating referrals [20, 21] as a number of interventions to save the lives of mothers, newborns, and child require better access to facility-based care in emergencies and, hence, stronger referral mechanisms from the community [10‐15] . For example, there is considerable evidence that emergency obstetric care (EmOC) reduces maternal and newborn mortality, however, inefficient functioning of referral systems often results in delayed treatment and poor outcomes [30]. A recent systematic review of evidence on referral interventions aimed at reducing maternal and newborn mortality found that many are ‘promising’ but conclusive evidence demonstrating their effect is scarce [31]. In addition, there are particular challenges in linking communities in moments of emergency (Figure 1).

The government of Tanzania has recently enacted policies aimed at continuing the long tradition of strengthening primary health care quality and access and the linkages between communities and health facilities. Tanzania’s Primary Health Services Development Programme (Mpango wa Maendeleo wa Afya ya Msingi, MMAM), calls for establishment of a dispensary in every village, a health center in every ward, and a cadre of community health workers and strengthening of referral systems [32]. The plan to introduce the new community health worker cadre is, however, still under development. Policy support and approval of the large-scale hiring of salaried community health workers awaits evidence of impact and sustainable costs. Efforts at improving referral have been piecemeal and face challenges in the essential linkage of community to facility.

To address this evidence gap, the Connect Project tests the hypothesis that introducing a formally trained and remunerated cadre of community health workers while improving district-level emergency referral systems will reduce child mortality. Additionally, it will improve access, utilization, and behaviors related to reproductive, maternal, newborn, and child health. Connect will also use quantitative and qualitative implementation data to provide operational guidance to the Ministry of Health and Social Welfare (MoHSW) in developing the community health worker cadre and strengthening emergency referral systems. Table 1 shows the core objectives of Connect.

A community-based cluster randomized trial design represents the most rigorous possible appraisal of the effectiveness of the community health agent (CHA) in the context of district health systems. The study is being implemented in three rural districts in Tanzania. The districts, and corresponding study villages, were selected to build upon previous and ongoing efforts to strengthen primary health care planning and facility services, as well as due to the presence of ongoing Health and Demographic Surveillance Systems (HDSS). The HDSS areas are comprised of 101 villages and 50 of those villages are randomly assigned to the CHA intervention. The village was chosen as the unit of randomization in order to align the design with the anticipated primary organizational unit of any national program that would recruit, train, and assign CHA to districts.

To date, 113 CHA have been deployed to all 50 randomly selected intervention villages as planned. The emergency referral component, which is a district wide intervention, has completed the planning process and a number of initial activities, such as provision of transport and initiation of the emergency support telemedicine system. Based upon triangulation of monthly reports from field implementation coordinators, monthly statistics from CHA, examinations from training, and preliminary analysis of qualitative interviews and focus groups with stakeholders from multiple levels, we have drawn some initial implementation findings, which are described in Table 4. These areas are still under research and, as the study progresses, will be verified.

The Connect research design, in general, permits a unique opportunity to test the added value of a community health worker program on reducing child mortality, as well as improving behaviors and care seeking related to reproductive, maternal, newborn, and child health with a rigor that has been rare in similar studies in Africa [20]. The project uniquely tests the delivery of an integrated package of reproductive and child health services at the household level, rather than focusing on one particular disease or particular type of service. Connect is also designed to address key research priorities related to strengthening emergency referral systems for MNCH. By combining these two elements, Connect seeks to test operational interventions that close gaps in the “vertical” continuum of care from household to health facility [70, 71]. Connect’s triangulation of demographic surveillance, cross-sectional panel surveys in households, and process evaluation will provide a rich picture of the programmatic and behavioral pathways that link program exposure, health systems strengthening, and changes in health outcomes and survival. These data are particularly important at a time when there are global calls to strengthen the continuum of care, including massive scale-up of community health workers in lower and middle income countries [68, 72].

Connect represents a rigorously evaluated study that addresses the design limitations of other studies that have been fielded for assessing the added value of community-based primary health care workers in Africa [73]. In addition to Connect’s significance in advancing evidence for global and regional purposes, perhaps, most importantly, its links to national policy create an opportunity to provide evidence in support of efforts to reform how primary health care is delivered across Tanzania.