Introducing Community Health Agents (CHA) to Accelerate Achievement of MDGs 4 and 5 in Tanzania: The Connect Project
The Connect Project
The research will test the hypothesis that introducing the community health agents (CHA) cadre into the Tanzanian health system and the necessary system supports, and emergency referral systems, will result in reduction of child mortality, particularly newborn mortality, and produce efficiencies and cost-savings in the health system. It has an experimental design to measure the impact of the CHA intervention and also systems and operations research to test the approaches and costs.
Tanzania has a comprehensive primary healthcare program that provides a wide range of essential preventive and curative services. However, the system also has gaps in the services, particularly at community level, that prevent it from achieving its full potential.
To address these problems, Connect aims to strengthen the capacity of the health system by introducing the CHA with the necessary systems support structures to function most effectively. The project will be guided in these efforts by a framework created by the World Health Organization. The framework has identified the six areas of focus that have been shown to be critical to effective health systems development (HSD):
1. Integrated primary healthcare interventions that are known to reduce morbidity and mortality;
2. A health workforce that is trained, deployed, and accessible for addressing healthcare needs;
3. Essential information that is required for healthcare workers to provide appropriate services;
4. Essential supplies, equipment, and facilities for providing basic healthcare operations;
5. Resources and social protection mechanisms to finance and ensure economic accessibility of services;
6. Mechanisms of leadership and governance that provide direction to health system operations.
1. Columbia University IRB, Jan 2012, ref: IRB-AAAF3452
2. National Institute for Medical Research (NIMR), Aug 2012
3. Ifakara Health Institute, June 2010
Two-celled randomized cluster trial
Primary study design
Secondary study design
Cluster randomised trial
Patient information sheet
Not available in web format, please use the contact details below to request a patient information sheet
Infant and child mortality, maternal mortality
The health workers will participate in focus group discussions and in-depth interviews on issues related to job satisfaction and retention and their expectations, reservations and ideas regarding the introduction of the CHA.
Connect is a randomized controlled trial by village cluster that contains a total of 101 villages 50 treatment and 51 control. Assignment of villages to the treatment or control arm followed probability proportionate to size sampling procedures which ensured that each arm was comparable with regards to the population size of the villages in them. No other variable was used in the sampling frame. Within the treatment arm the number of CHA assigned to each village also followed probability proportionate to size methods whereby intervention villages with fewer than 1000 population received 1 CHA; villages with 1000-3999 population received 2 CHA; villages with 4000 6999 population received 3 CHA and villages with over 7000 population received for 4 CHA.
The CHA intervention integrates various primary health care functions into a single community-based work package that includes all stages of the oft-cited continuum of care: routine household visits and community education sessions focused on (a) general primary healthcare education and promotion; (b) comprehensive family planning including distribution of condoms and oral contraceptives, and education and focused referral for long term and permanent acting methods; (c) focused referral for antenatal care for pregnant women; (d) birth planning and referral assistance to ensure institutional delivery; (e) essential newborn care education and promotion and referral assistance for sick newborns; (f) community case management for malaria, diarrhea, and pneumonia; (g) general first aid other community health promotion functions; (h) HIV/STI prevention education, including condom distribution. The number of sessions is variable according to the various contextual and individual factors that affect CHA performance and this is followed through program monitoring processes.
There will be 12 focus group discussions on this issue (120 participants) and 12 in-depth interviews (12 subjects). The focus group discussions with community members will be about:
1. Family planning
2. Postnatal care and service seeking behavior, and
3. Health and care-seeking behaviors of women during pregnancy and delivery.
The family planning discussions will be held with men (married, aged 30-49) and women (married, aged 25-49) groups separately. The latter two types of focus group discussions will enroll women that had newborns in the past 12 months. For each of these focus group discussion types there will be the same number of subjects as laid down in the above discussion of health workers (120 focus group subjects and 48 in depth interview subjects).
Primary outcome measures
The following discussion provides a subject population description for the three components of phase 1:
1. Sampling Research: This involves the use archival de-identified summary data that reflects the subject accrual of some 350,000 people in the Ifakara and Rufiji health and demographic surveillance system (HDSS). The catchment area of these HDSS areas is comprised of the village clusters that we will randomize into our study by the end of this phase. The Connect project will not enroll these people, but will use de-identified summary statistics that reflect on this population in order to inform our randomization.
2. Baseline Research (3000 subjects total, see below): this will involve the accrual of human subjects that reside within the catchment population of the Ifakara and Rufiji HDSS. The household survey will include roughly 3000 households. Households can be included only if they are among those accrued in the Ifakara and Rufiji HDSS and have women of reproductive age (15-49 years of age) and be the primary care takers of at least one under-five year old child. The population to be enrolled as participants in the household survey will, in most cases, be non-English speaking, educationally- and economically disadvantaged. Kiswahili is the national language of Tanzania and residents of rural villages are typically impoverished and with limited means to adequate schooling. An additional special populations that will figure prominently in this survey are pregnant women, which stands to reason given the objectives of Connect and its core impact and outcome indicators which are well explained in the attached protocol and study description. No children or minors will be enrolled.
3. Formative Research: With respect to the formative research, it will be conducted amongst health workers and members of the study population. The health workers will participate in focus group discussions and in-depth interviews on issues related to job satisfaction and retention and their expectations, reservations and ideas regarding the introduction of the CHA. The family planning discussions will be held with men's (married, aged 30-49) and women's (married, aged 25-49) groups separately. The latter two types of focus group discussions will enroll women that had newborns in the past 12 months.
Secondary outcome measures
1. Maternal mortality
2. Cause of death, fertility
3. Childhood morbidity
4. Burden of disease life years gained and key maternal and child health behaviors
Additional, key secondary outcomes cover a range of relevant reproductive, maternal, newborn and child health seeking and service utilization behaviors and are gathered at baseline and end-line using a sub-HDSS panel survey which is linked to the HDSS using shared respondent IDs. Baseline data were collected between May and July 2011 and the end-line data will be collected during the same period in 2015.
Overall trial start date
Overall trial end date
Participant inclusion criteria
1. Human subjects that reside within the catchment population of the Ifakara and Rufiji HDSS.
2. The household survey will include roughly 3000 households. Households can be included only if:
2.1. Have women of reproductive age (WRA) (15-49 years of age) or be the primary care takers of at least one under-five year old child for women more than 49 years old.
2.2. The population to be enrolled as participants in the household survey will, in most cases, be non-English speaking, educationally- and economically disadvantaged. Kiswahili is the national language of Tanzania and residents of rural villages are typically impoverished and with limited means to adequate schooling. No children under the age of 15 will be enrolled. All WRA will be enrolled as subjects.
3. Health workers Any Community Health Agents and government health employees within the study districts.
Target number of participants
Participant exclusion criteria
Does not meet inclusion criteria
Recruitment start date
Recruitment end date
Countries of recruitment
Trial participating centre
60 Haven Ave
United States of America
Doris Duke Charitable Foundation DDCF 2009058 (USA)
Funding Body Type
private sector organisation
Funding Body Subtype
United States of America
Comic Relief (UK)
Funding Body Type
Funding Body Subtype
Results and Publications
Publication and dissemination plan
Not provided at time of registration
Intention to publish date
Participant level data
Not provided at time of registration
Results - basic reporting
Ramsey K, Hingora A, Kante M, Jackson E, Exavery A, Pemba S, Manzi F, Baynes C, Helleringer S, Phillips JF, 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., BMC Health Serv Res, 2013, 13 Suppl 2, S6, doi: 10.1186/1472-6963-13-S2-S6.
Tani K, Exavery A, Baynes CD, Pemba S, Hingora A, Manzi F, Phillips JF, Kanté AM, Unit cost analysis of training and deploying paid community health workers in three rural districts of Tanzania, BMC Health Serv Res, 2016 , 16, 1, 237.