Developing intervention strategies: innovations to improve community health worker motivation and performance

8/12/2019 Developing intervention strategies: innovations to improve community health worker motivation and performance

1/28


2/28

Since starting operations in 2003,

Malaria Consortium has gained a great deal o

experience and knowledge through technical and

operational programmes and activities relating

to the control o malaria and other inectious

childhood and neglected tropical diseases.

Organisationally, we are dedicated to ensuring

our work remains grounded in the lessons we

learn through implementation. We explore

beyond current practice, to try out innovative

ways through research, implementation and

policy development to achieve effective and

sustainable disease management and control.

Collaboration and cooperation with others

through our work has been paramount and much

o what we have learned has been achieved

through our partnerships.

This series o learning papers aims to capture and

collate some o the knowledge, learning and,

where possible, the evidence around the ocus

and effectiveness o our work. By sharing thislearning, we hope to provide new knowledge

on public health development that will help

influence and advance both policy and practice.

Mozambique: Community health worker, Fernando Zacule,

makes a home visit to check on a young patient

Photo: Ruth Ayisi / Malaria Consortium

The Learning Papers

Series

Developing Intervention Strategies

[ to improve community health worker

motivation and performance ]

Authors:

Tine FrankConsultant

Dr Karin KllanderRegional Programme Coordinator, Malaria Consortium

Contributors:

Eleni CapsaskisRegional Communication Specialist, Malaria Consortium

Madeleine Marasciulo-RiceCase Management Specialist, Malaria Consortium

Daniel StrachanSenior Research Associate, University College London

Editor:

Diana ThomasSenior Communications Manager, Malaria Consortium

Contact:

[email protected]


3/28

CONTENTS

[ 2 ] Introduction

[ 4 ] The process

[ 5 ] Step 1

Existing experience and theory

[ 8 ] Step 2

Creating interventions inormed

by theory

[ 12 ] Formative research

[ 15 ] Step 3

Materials and monitoring tools

[ 18 ] Moving orward

[ 20 ] Lessons learnt

[ 25 ] Reerences


4/28


5/28

[3 ]

Minimally trained CHWs need regular, supportive supervisionto operate effectively;

yet distances to health acilities and district offices and lack o transportation,

coupled with poorly developed management inormation systems, present a

continuous challenge to implementation o effective supervision.

Motivation through remuneration or otherwise o CHWs is a critical barrier

in most countries. Many governments are reluctant to allocate unds and create

thousands o new civil servant posts, yet lack alternative approaches to motivate

CHWs to keep their health provision serv ices effective and operational.

Documentationo programme implementation processes and results, andsharingo solutions with districts about to start implementation, is scarce,

leading to continuous and significant waste o time and resources.

Three main implementation

barriers to be addressed

a project to address these barriers through

a project called inSCALE. Innovations at

Scale or Supporting Community Access

and Lasting Eects. inSCALE committed to

identiy and test innovative solutions that

can acilitate sustainable scale up o ICCM

in Arican countries.

inSCALE aims to demonstrate that coverage

and impact o government-led ICCM

programmes can be ex tended i innovative

solutions can be ound or critical limitations,

such as motivation and retention o CHWs.

Once easible and acceptable solutions are

identified, these can be used to increase the

coverage o ICCM and improve its quality so

that more children under the age o five have

prompt access to appropriate treatment.

In order to reach the end objectives, several

different clinical as well as behavioural

outcomes must be met and, thereore,

many different actors would need to be

influenced rom community members,

CHWs and health workers to district and

government officials. To achieve this, Malaria

Consortium ormed a multi-disciplinary

team - the inSC ALE technical team bringing

together clin ical and technical experts,

epidemiologists, social scientists and health

economists. A key actor to success has been

this teams in- depth involvement at each and

every stage o the process, resulting in the

design o a finely-tailored set o evidence

based intervention strategies.

Over the period rom January 2010 to

August 2012, the inSCALE technical team

developed two intervention packages two or

Uganda and one or Mozambique designedto positively influence motivation, retention

and perormance amongst CHWs. The first

approach involving technology based activities

is to be implemented in both countries and

the second, through community based

innovations, in Uganda only.

This paper summarises the process adopted

by inSCALE or identiying the barriers

to CHW motivation and per ormance in

Uganda and Mozambique and documents

innovative solutions to these challenges

that are potentia lly acceptable and eas ible,

including the rationale or the design o the

two interventions developed.

inUganda

141,000children die beore their

5th birthday; o these

56,000rom pneumonia,

malaria and diarrhoea*

in

Mozambiquepneumonia, malaria and

diarrhoea account or

44% odeathsin under-fives

*

* www.countdown2015mnch.org


6/28

[4 ]

The process

The rigorous process employed, which led

to the design o two innovative intervention

packages, has been based on a combination

o methods designed to understand better

the main obstacles or regular and effective

supervision and motivation o CHWs. In

addition to applying underlying theories

o worker motivation, a key element in

the process was to truly understand how

context could impact upon CHW motivation

and perormance beore identiying and

developing potential solutions.

Following each step o the process, the

inSCALE team gathered to evaluate findings

in order to inorm and determine the activities,

research, or urther reviews necessary or

the design o the next step. The net was

thrown wide at the start, so that these

meetings served to systematically distil

inormation and refine ideas at each and

every step, and involved all members o

the inSC ALE technical team throughout.CHW (known as a village health

team member or VHT) Sewanyana

Christopher keeps a record o his

trea tment o a you ng c hild,

Hoima, Uganda


7/28

[5 ]

At the beginning o the inSCALE project a

variety o reviews and consultations took

place to ensure interventions designed

drew on experience rom previous work and

appropriate theory. There was an additional

ocus on using these sources to identiy

areas o legitimate need with genuine

potential or innovation. An initial team

meeting determined the decision process

on what to review and why, and areas to be

covered were identified. The result was the

three strands descr ibed below, which wereallocated to team members with relevant

expertise, each o whom carried out extensive

reviews, the findings o which were presented

and discussed in subsequent meetings.

Literature reviewsExisting literature on 10 different subjects

within the areas o supervision, motivation

and incentives (including payment or

perormance), data use in quality improvement,

mHealth, community development, andmanagement, business and human resources

was thoroughly reviewed and relevant

inormation extracted. Off target areas,

such as corporate approaches, were included

to provide a resh perspec tive to stimulate

discussion and debate.

History andex revews

The historical contexts o Uganda andMozambique as they related to CHW

programmes were reviewed to ensure any

precedents were considered [2]. The way

routine data flowed through health

inormation systems was also documented.

The inSCALE project countries differ greatly in

their CHW programmes, making this exercise

essential to understanding which innovations

may work and how to embed them into

current structures. One major difference,

or example, was CHW coverage.

Step 1

Exs experee d hery

Step 1Understanding relevant programme experience and theory

ITERATURE REVIEWS THEORYEXPERT CONSULTATIONSBEST

HEORYEXPERT CONSULTATIONSBEST PRACTICESEXPERIENC

XPERT CONSULTATIONSBEST PRACTICESEXPERIENCEPOTEN EST PRACTICESEXPERIENCEPOTENTIALCONTEXT LITERATU

XPERIENCEPOTENTIALCONTEXT LITERATURE REVIEWS THE

OTENTIALCONTEXT LITERATURE REVIEWS THEORYEXPERT C

ONTEXT LITERATURE REVIEWS THEORYEXPERT CONSULTATI


HEORYEXPERT CONSULTATIONSBEST PRACTICESEXPERIENC

XPERT CONSULTATIONSBEST PRACTICESEXPERIENCEPOTEN

EST PRACTICESEXPERIENCEPOTENTIALCONTEXT LITERATU

XPERIENCEPOTENTIALCONTEXT LITERATURE REVIEWS THE

OTENTIALCONTEXT LITERATURE REVIEWS THEORYEXPERT C

ONTEXT LITERATURE REVIEWS THEORYEXPERT CONSULTATI


XPERT CONSULTATIONSBEST PRACTICESEXPERIENCEPOTENTIAL

EST PRACTICESEXPERIENCEPOTENTIALCONTEXT LITERAT

ICESEXPERIENCEPOTENTIALCONTEXT LITERATURE RE

LCONTEXT LITERATURE REVIEWS THEORYEXPERTTURE REVIEWS THEORYEXPERT CONSULTATIO

THEORYEXPERT CONSULTATIONSBEST P

ERT CONSULTATIONSBEST PRACTICES

TATIONSBEST PRACTICESEXPERIE

SEXPERIENCEPOTENTIALCONT

NCEPOTENTIALCONTEXT LI

LITERATURE REVIEWS THE

WS THEORYEXPERT C

XPERT CONSULTATIO

ULTATIONSBEST P

BEST PRACTICES

IENCEPOTENTI

TENTIALCONT

TURE REVIE

HEORYEXPE

T CONSULT

TIONSBES

T PRACTI

CEPOTE

NTIALCO

RE REVI

ORYEX

CONSU

IONSB

PRACTI

CEPOT

TIALC

RE REVI

ORYEX

CONSU

LITERA

TURE

REV

IEWS

BEST PRACTICES

EXPERIE

NCE

EXPERIENCEPOTENTIAL

CONTEXT

CONT

EXT

LITER

ATUR

EREV

IEW

SLITERAT

UREREVIEWS

LITERATUREREVIEWS

EXPERTCONSULTATIONS

EXPERT

CONS

ULTA

TIONS

EXPERTCONSULTATIONS

THEORY

THEO

RY

THEO

RY

THEO

RY

BEST PRACTICES

BEST

PRACTIC

ES

BESTPRACTICES

BESTPRACTICES

EXPERIENCEEXP

ERIENCE

EXPERIENCEEX

PERIEN

CE

EXPE

RIEN

CE

POTENTIAL

POTENTIAL

POTENTIAL

POTENTIAL

POTENTIAL

CONTEXT

CONT

EXT

CONTEXT

CONT

EXT

EXPERTCONSULTATIO

NS

BESTPRACTICES EX

PERIEN

CE

CONT

EXT

INNOVATIONS

EXPERT CONSULTATIONS THEORY


8/28

[6 ]

In Mozambique, one CHW covers approximately

2,000 community members who live 8-25km

rom a health acility, whereas Ugandan

CHWs should be present in all villages and

typically cover between 250 and 500 people.

Such a variation would affect the easibility

o some innovations, so it was important

that adjustments were made to the design o

the intervention packages or each country.

Exper sulsFifeen international stakeholders with a wide

range o programme and research experience

related to CHWs were consulted to elicit

their views, learn lessons and catalogue

recommendations relevant to innovative

practice [3]. Some undamental issues were

highlighted here that were not necessarily

relevant to the implementation o the

inSCALE project (or example the importance

o community-led CHW selection as opposed

to appointments by village leaders or district

officials), but were documented to serve as

important key recommendations to other

districts or countries implementing ICCM

programmes in the uture.

This exercise helped distil and clariy best

practices that are already known to work and

thereore would need no urther testing and,

equally, identiy approaches that had shown

promise but had not been tested sufficiently.

Using the findings, a detailed ramework was

developed using proposed models [4] or low-

income countries combined with motivation

and incentives theory. The purpose o this

ramework was to inorm the development

o interventions and provide guidance when

seeking to understand their impact.A CHW practices using a mobilephone with the inSCA LE interace

to se nd data


9/28

[7 ]

Culture

d ex

Community attitudeto health and i llness

Policy

Parent andcommunityexpesof CHWs

Relationship

Encounter expectations

Treatments vs. prevention

CHWcharacteristics

Demographics

Knowledge / education

Expectations

Countryhealth system

Investment

Programme structure andenvironment including strategyand resources

Motivation toperform:

Individual

Needs satisaction

Sel efficacy

Programme commitment and goals

Outcome expectancies

Intentions

Social

Identity

Environmental

Workload

Geography

Justice / equity

Job security

Management / supervision support

Respect

Expereeof outcomes

Performanc

e

Retention

Selection / recruitment

Incentives

Training

Supervision

mHealth

Data use

Community involvement /engagement

Framework to inorm development o interventions to influence perormance and retention o CHWs

What inSCALE seeks to understand when designing the

interventions and what will inorm their impact

What the project seeks to influence through interventions

Factors proposed as o greatest relevance to CHW motivation

Project outcome

Project outcome


10/28

[8 ]

N SUPERVISION FEASIBILITY INNOVATIVE TECH

ON FEASIBILITY INNOVATIVE TECHNOLOGY

INNOVATIVE TECHNOLOGY COMMUNIT

CHNOLOGY COMMUNITY PILE SORT

MMUNITY PILE SORTING STAK

E SORTING STAKEHOLDERS F

EHOLDERS FORMATIVE R

MATIVE RESEARCH BES

CH BEST BETS MOTI

TIVATION SUPERV

FEASIBILITY INN

Y INNOVATIVE

TECHNOLOGY

COMMUNIT

Y PILE SORTI

G STAKEH

ERS FORME RESEAR

EST BETS

TION SU

SIBILITY

NOVATI

CHNOLO

OMMUN

PILE SO

STAKE

S FOR

RESEA

BEST BETS MOTIVATION SUPERVISION FEASIBILITY INNOVATIV

MOTIVATION SUPERVISION FEASIBILITY INNOVATIVE TECHNO

SUPERVISION FEASIBILITY INNOVATIVE TECHNOLOGY COMMU

FEASIBILITY INNOVATIVE TECHNOLOGY COMMUNITY PILE SO

INNOVATIVE TECHNOLOGY COMMUNITY PILE SORTING STAKE

TECHNOLOGY COMMUNITY PILE SORTING STAKEHOLDERS FO

COMMUNITY PILE SORTING STAKEHOLDERS FORMATIVE RESE

INNOVATIONS

MOTIV

ATION

FEASIB

ILITY

STAKEH

OLDERS

BESTBETS

BESTBETS

BESTBE

TS

MOTIVATION

MOTIVATION

MOTIVATION

MOTIV

ATION

SUPERV

ISION

SUPERVISI

ON

FEASIBILITY

FEASIBILITY

INNOVATIVE

INNO

VATIV

E

TECHNOLOGY

TECHNOLO

GY

COMMUNITY

COMMUNITY

PILESORTING

PILESORTING

STAKEHO

LDERS

STAKEH

OLDERS

FORM

ATIVER

ESEA

RCH

BEST

BETS

SUPERVISION

INNO

VATIV

E

TECH

NOLO

GY

COMMUNITY

PILESORTING

Step 2Creating interventions inormed by theory

Following on rom the evaluation o theoretical

findings, the inSCALE team began the

extensive process o narrowing down potential

intervention methods and innovations still

urther. Some were identified as best practices

and added to the resource bank while others

were sorted in to best bets or the Uganda

and Mozambique contexts.

The best betsFrom the reviews o theory and previous

experience, a long list o potential activities

using innovative approaches was drafed.

Using a standard table that was designed

or extraction o interventions (description,

source, methods, easibility, moderators),

the team worked on compiling this l ist

independently. During team meetings, the

best bets being the most relevant, easible

and innovative approaches within the project

time rames were presented and discussed.

Ultimately, our to five were selected based

on ratings or:

impact potential

ability to ulfil required needs

acceptability

easibility and sustainability

Step 2

Creating interventions

informed by theory


11/28

[9 ]

From the start, the inSCALE project intended

to develop two different intervent ions

to address motivation and supervision

respectively. However, during the first

step which ocused on understanding the

underlying theory, what emerged was that

the two areas were not easily separated, but

rather interlinked. Thereore, a decision was

made to change the approach to designing

two intervention packages that each addressmotivation and supervision but in very

different ways. From this final selection,

appropriate innovative activities were

decided on and grouped into two clusters:

a technology arm and a community based arm.

Both these approaches aimed to positively

influence CHW motivation and retention by

promoting their sense o collective identity.

By the end o the best bets exercise, the

list was narrowed down to 17 potential

innovations under the technology arms

and 13 under the community one or

Uganda, and seven and five respectively

or Mozambique. As project activities were

a step ahead in Uganda, decisions made

or Mozambique would partly be based

on lessons learnt in Uganda with activities

streamlined and combined accordingly.

Promoting CHW learning and support using inormation communication

technology (ICT) to improve CHW perormance, motivation and retention.

When ace to ace contact is inrequent, this approach aims to use low cost

technology, through the development o tools and appl ications or mobi le

phones, to increase CHWs eeling o connectedness to the wider health system.

The approach will be used to support motivation through sel learning, provision

o job aids, assist with data submission, and provide individual perormance

related eedback. It is also intended to provide support supervision, and offer

problem solving and peer-support. The mobile phones themselves provide the

added benefit o being symbolic o status.

1. Technology supported approach

Given the large number o

reviews produced by the

team, the best bets approach

was suggested as a way o

speeding up the discussion

and selection process. This

exercise was incredibly

successul and helpul as it

ensured that every team

member received an overview

o each topic area and had

an opportunity to compare

and contrast the best bets

suggested rom all reviews

Karin Kllander, Regional Programme

Coordinator, inSCALE,

Malaria Consortium

Promoting CHWs as key village health assets to improve CHW perormance,

motivation and retention.

This approach aims to enhance the perceived value o the CHW, both or

themselves and or the communities they serve, through inclusive and

participatory local activities. This will not only lead to greater status or CHWs,

but will also increase demand or their services, contributing to the sustainability

o their role.

2. Community supported approach


12/28

Pile sorting

Working with key personnel rom Ministries

o Health at district and national level in

Uganda and Mozambique respectively,

discussions were held to establish individual

stakeholders views on the easibility and

acceptability o potential activities by ranking

them. Pile sorting methodology [5] was then

used to create a shortlist o activities to take

to development stage, a process which gave

useul insights into participants perceptions.As a secondary benefit, this step o the

process also encouraged early understanding

o the inSCALE project amongst key

government officials.

In Uganda, a total o five interviews and

three group sessions were conducted,

involving 23 participants. In Mozambique,

five interviews and five group discussions

took place. Based on the eedback, the

inSCALE team was able to narrow down the

list o potential innovations to the ollowing:

In Uganda, five o the eight proposed

community based activities were dropped

or incorporated into relevant ones

being taken orward to the next step o

development. Four out o 10 under the

technology arm were also dropped.

Due to external delays and project time

constraints, just one intervention package

was developed or Mozambique; the

technology supported arm, narrowed downto s ix activities at this stage. The main

reasoning behind choosing the technology

approach over community activities was

based on pile sorting findings, which

highlighted that the local CHW strategy

already incorporated substantial community

components. Although these might not be

working to optimal capacity, the proposed

community activities were not thereore

seen as par ticularly innovative or the

Mozambique context.

DROPPED by Uganda

stakeholders, despite

being seen as overall

easible and acceptable:

Activity: Post-training

orientation community

meeting to clariy CHW

role and understand all

stakeholder expectations

Decision: Dropped

Justification: Stakeholders

emphasised that this is

already a recommended

activity in the strategic

guidelines and will not

thereore be innovative

DROPPED by Uganda

stakeholders asconsidered to have

low easibility:

Activity: Outsourcing

supervision to a new

cadre o non-health

worker supervisors using

best practice recruitment

approaches

Decision: Dropped

Justification: Stakeholders

elt that the country is not

yet ready or this activity

Mozambique: CHWs consider options or the

best approach to provide them with support

[10 ]


13/28


14/28

[12 ]

With the final list o 15 potential activities

across the two intervention packages in

two countries, the general struc ture o

the interventions had been defined. The

ormative research stage would now help

fine-tune the activities by gauging the views

o the CHWs, their supervisors, district officials

and key programme implementers, as well

as caregivers, heads o households and

traditional community leader s, on

the ollowing:

The potential or the proposedinnovations to meet genuine needs and

have an impact (in terms o meeting

project aims)

The easibility o implementation and

scale up o the proposed activities

The acceptability o the proposed

activities to the CHWs themselves, their

supervisors, communities, districts and

the Ministry o Health

Field workers were recruited and trainedto carry out the ormative research in two

rounds in Uganda one ocusing on the

technology arm and one on community

innovations. In Mozambique there was one

technology based round, which was ollowed

by a pilot CHW interview and ocus group

discussion. The eedback rom this led to

amendments to the data collection guides,

which were trialled again in a different

district, and then finalised.

In Uganda, 61 in depth interviews and 15

ocus group discussions were conducted in

total or both intervention packages. The

Mozambique ormative research (again,

with lessons learnt rom Uganda) included

26 in depth interviews and our ocus group

discussions or the technology intervention.

Formative researchdsIn both Uganda and Mozambique, CHWs find

positive eedback and acknowledgement o

their work motivating. They value perormance

ocused supervision as this provides them

with knowledge to improve how they serve

their community. However, health aci lity

supervision is ound to be sporadic due to

work loads and transport costs.

ResultinginterventionsFor both countries, conducting perormance-

based supervision over the phone may reduce

travel needs and make supervision more

efficient. The inSCALE project is developing

a system by which CHWs can submit ICCM

data using mobile phones, with immediate

automated, personalised perormance related

eedback. To implement this, job aids and /or

additional training will be required to

assist supervisors.

In Uganda, supervisors oversee between

25-90 CHWs each, making regular community

supervision difficult. The data submission

component will be used to target community

visits to the weakest CHWs, whereas the

better perorming ones will be encouraged

to keep motivated via mobile phone messages.

In Mozambique, where supervisors only

oversee 2-3 CHWs each but long distances

make supervision irregular, the intervention

will instead be designed to help the supervisor

ocus on topics which CHWs find difficult and

which will need to be addressed in supervision

meetings, either ace to ace or over the

phone using competency checklists.

In Uganda

61in-depthinterviews and

15ocus groupdiscussions were conducted

or both packages

In Mozambique ormative

research included

26in-depthinterviews and

4ocus groupdiscussions or the

technology inter vention

Formative research

CHWs in Uganda review the process

o setting up a village health club

Photo: Paula Valentine / Malaria Consortium


15/28

[13 ]

Mozambique Uganda

Communities use the CHWs, think their

work is important and respect them;

a supportive relationship that is valued

by the CHWs.

Status and community standing is

important to CHWs; yet many eel

that thei r work and aims are not well

understood in their communities.

THEREFORE

Innovation design should highlight

community support and use terminologymeaningul to CHWs, such as reputation,

respect and recognition.

Innovation design should aim at

increasing CHW standing and statusto improve motivation by, or example,

encouraging a higher level o involvement

by community leaders in CHW work.

Formative Research Findingsillustrating differences between

Uganda and Mozambique


16/28

[14 ]

Village owned CHW ocussedOpen to allA strength

based approachFun and purposeul

VILLAGE HEALTH CLUBS

Discuss and rank child health challenges

Discuss solutions to challenges, which include supporting the unc tioning o CHW services

Club members take actions to meet these challenges

Health clubs will monitor, report and communicate on their progress

SUPPORT AND

SUPERVISIONCONNECTEDNESS

STANDING, STATUS,

IDENTITY AND VALUE

CHW submitting data

using phones and

receiving personal

perormance related

eedback

CHW and supervisor

using Closed User Groups

or remote supervision,

planning supervision

visits, problem discussion

and solving

CHW receiving monthly

motivational SMS

CHW data on server

trigger ing SMS aler ts on

good and bad perormance

to super visor with hint s

on which action to take

PROVISION OF AFFORDABLE MOBILE PHONES AND SOLAR CHARGERS

The data rom this extensive qualitative

research exercise was analysed and

synthesised into three different ormative

research reports. The outcomes were

then presented at workshops where the

implications or the acceptability and

easibility o the proposed innovation were

Two approaches to improve motivation and perormance o CHWs

discussed. Final decisions were made on the

activities that would ulfil the aims o the

project in the most effective way possible.

The result: two intervention packages,

ollowing different paths to achieving

the same objectives , ready or design,

development and pre-testing.


17/28

[15 ]

At the conclusion o the theory and

research stage, the inSCALE team had

deined two intervention strategies or

inluencing CHW motivation and retention

in two dierent ways.

Innovations under the technology arm were

clearly outlined, allowing or extensive

development o innovative mobile phone

sofware and intricate eedback systems

including: weekly report phone interace;

eedback messages or CHWs; algorithms

that will generate flagged messages or

supervisors; and monthly motivational

messages or CHWs.

While technology arm design process

was relatively linear, the community arm

development and design process was

circular, moving back and orth between

findings rom Steps 1 and 2. Eventually this

evolved into the Village Health Clubs, a

participatory approach resting on five key

pillars, using a our-step cycle to engage

community members. This bottom up

approach promoting inclusivity, equality,

airness, with a ocus on pulling together to

take health action to seek solutions to ch ild

health problems - was chosen rom several

proposed community based solutions

ollowing positive eedback during testing

in three field sites.

Once the design and development stages

were concluded, these strategies were

prepared or implementation: the contents oeach message were finalised, and supporting

materials developed, tested and produced.

To support the activities and monitor the

train ing to ensure the qual ity o the

implementation, a large number o training

materials, job aids and monitoring tools

were designed in English and Portuguese.

Step 3

Materials and monitoring tools

Step 3Design, development and pre-testing o interventions

N SUPERVISION FEASIBILITY INNOVATIVE TECH

ON FEASIBILITY INNOVATIVE TECHNOLOGY

INNOVATIVE TECHNOLOGY COMMUNIT

CHNOLOGY COMMUNITY PILE SORTMMUNITY PILE SORTING STAKE

E SORTING STAKEHOLDERS F

EHOLDERS FORMATIVE R

MATIVE RESEARCH BES

RCH BEST BETS MOTI

OTIVATION SUPERV

FEASIBILITY INN

Y INNOVATIVE

TECHNOLOGY

COMMUNIT

Y PILE SORTI

G STAKEH

ERS FORM

E RESEAR

EST BETS

TION SU

SIBILITY

NOVATI

CHNOL

OMMUN

PILE SO

STAKE

S FOR

RESEA

BEST BETS MOTIVATION SUPERVISION FEASIBILITY INNOVATIV

MOTIVATION SUPERVISION FEASIBILITY INNOVATIVE TECHNOL

SUPERVISION FEASIBILITY INNOVATIVE TECHNOLOGY COMMU

FEASIBILITY INNOVATIVE TECHNOLOGY COMMUNITY PILE SO

INNOVATIVE TECHNOLOGY COMMUNITY PILE SORTING STAKE

TECHNOLOGY COMMUNITY PILE SORTING STAKEHOLDERS FO

COMMUNITY PILE SORTING STAKEHOLDERS FORMATIVE RESE

INNOVATIONS

MOTIV

ATION

FEASIB

ILITY

STAKEH

OLDERS

BESTBETS

BESTBETS

BESTBE

TS

MOTIVATION

MOTIVATION

MOTIVATION

MOTIV

ATION

SUPERV

ISION

SUPERV

ISION

FEASIBILITY

FEASIBILITY

INNOVATIVE

INNO

VATIV

E

TECHNOLOGY

TECHNOLO

GY

COMMUNITY

COMMUNITY

PILESORTING

PILESORTING

STAKEHO

LDERS

STAKEH

OLDERS

FORM

ATIVE

RESEAR

CH

BESTBETS

SUPERVISION

INNO

VATIV

E

TECHNOLO

GY

COMMUNITY

PILESORTING


18/28

[16 ]

To ensure the materials developed and

produced would contain valid and appropriate

messaging to be as effective as possible,

extensive pre-testing was conducted involving

community and end user eedback. For

example, responses to the wording and

structure o 12 motivational text messages

(SMSs) were gathered rom 39 CHWs in Uganda,

with results incorporated in the final design.

Likewise, or the community approach,

20 community members and CHWs assessed

images and key messages designed or

job aids .

Inormation or CHWs on how

to set up and run a vi llage

health club

PERIOD OFaction 3-4

WEEKS

MEETING 2

Prioritising child health

problems; finding out

causes and solutions;

taking action at home

MEEting 4

Reviewing our actions:

How did we get on?

What more do we

need to do?

MEETING 3

Finding solutions and

taking action together

Pre-es f merls

MEETING 1

Club ormation


19/28

[17]

Training Materials Job Aids

Communityapproach

Training o Trainers Guide, including:

individual progress chart, peer

observation orm, CHW workshop

evaluation orm, and CHW training

report

Sensitisation brie or sub-county

trainers to advocate or V illage Health

Clubs with other key stakeholders atcommunity / sub-county levels

Flipbook o child illness cards to

acilitate the our-step process and

provide participatory question

and answer sessions on malaria,

pneumonia, diarrhoea, malnutrition

and danger signs in newborns and

older children

Starter kit or acilitators, includingstationery or meetings, certificates

o achievement, membership cards,

ink pad or LC1 stamp; T-shirts or

CHW acilitators, and carry bag or

the whole ki t

Evaluation orms and attendance

registers

Technology

approach

Training o Trainers Workbook

or CHW Supervisors

Facilitators Guide to training on

the inSCALE Mobile CHW System

Solar Charger Usage Policy

and Guidelines

Mobile Phone Usage Policy

and Guidelines

Instructional DVD on mobile phone

and solar charger usage

How to Use the Nokia Mobile Phone

and Solar Charger guide

Sending Weekly Reports on the Nokia

Mobile Phone guide

Mock ICCM register weekly reports

Evaluation orms and attendance

registers

Supervisiontraining

Four Corners o Supervision handout

Supervising the Supervisor guide

including evaluation orm

Supervising the Sub-County

Supervisor guide

Trainer competency check list

Trainer perormance appraisal sheet

CHW supervisor competency checklist

CHW supervisor perormance

appraisal sheet

CHW Competency Checklist

Mobile CHW System

CHW Perormance Appraisal Sheet

inSCALE Mobile CHW System

Training materials, job aids and monitoring tools designed in English and Portuguese


20/28

[18 ]

The community armThe community based approach in Uganda

will involve 800 CHWs across five distric ts.

The first step in the training cascade was to

train 39 development officers, health acil ity

in-charges and health assistants have been

trained as sub-county trainers in adult learning,

participatory empowerment methodology,

and the village health club approach. These

trainers are, in turn, training two ICCM CHWs

in each village as village health club acilitators

with initial practical guidance and support

rom the inSCALE and district master trainers.

The trained CHWs will then work with their

peers to mobilise community members to

set up and run health clubs in their village.

Sub- county trainers will carry out ollow up

and supportive supervision visits to CHWs to

assess their core competencies in deliveringICCM, thus ensuring smooth set up and

running o the village health clubs.

The technology armIn Uganda, the technology intervention

will cover 1,350 CHWs across eight districts .

Supervisors have already been trained

as trainers on the inSCALE mobile CHW

system and effective supervision sk ills

using core competency assessment tools,

and are now training the ICCM CHWs

initially with the support o Malaria

Consortium master trainers. Trained CHWs

will return to their villages with mobile

phones and solar chargers to assist their

work in the community, and sub-county

trainers will carry out ollow up and

supportive supervision visits to ensure

that appropriate, qual ity care is delivered

and that mobile phones are being used

appropriately and to maximum effect.

In Mozambique, the project area or the

technology intervention will be six o the

12 districts in Inhambane province. All district

and health acility supervisors, as well as the

district CHW coordinators in the intervention

districts, will be trained as trainers to deliver

the CHW mobile system and provide support

supervision or the 150 CHWs in the area. As

in Uganda, Malaria Consortium will provide

training support, both or in itial training o

trainers and or trainers in how to carry out

support supervision.

Moving forward

over he ex 12 mhs, he prje wl l ssess hw effeve

the interventions have been in achieving their primary goals

of increasing motivation and improving performance among

CHWs. The process will be reviewed to establish whether

interventions were delivered as designed, inform whether

remedl s eessry d fesble, d expl hw

d why he erves wrk r d wrk. a ed-le

survey will evaluate the difference in CHW motivation and

performance between intervention areas and a control group,

and the proportion of children treated appropriately.

A Ugandan CHW rom Kyankwanzi district,

Western Uganda, sends data about his patients via SMS

In Uganda

800CHWs areinvolved in the community

based approach and

1,350in thetechnology intervention


21/28


22/28

[20 ]

Successes There is much to learn about CHW

supervision and incentives by reviewing

health worker literature; even where

evidence is limited, a literature review

can be useul to garner ideas and can

make an important contribution to

decision making. Similarly, literature

reviews rom off target areas such as

the business world can offer a resh

perspective and provide useul insightsand ideas. The rigorous review process,

though time consuming, was key in

enabling the inSCALE team to make

invaluable changes in assumptions

early on in the project.

Early on in the project, mobile phone

numbers or the majority o the CHWs

(over 7,000) trained in the nine districts

in Uganda were collected, which proved

a very useul resource or understanding

CHWs access to mobile phone networksand or pre-testing SMS messages.

A locally established call centre carried

out phone interviews with CHWs an

immensely time-saving approach replacing

the need or numerous field vi sits.

Taking a theoretical view o motivation

and retention helps identiy innovations

and their potential effect, particularly

when evidence is lacking. It also helps

understand how innovations may

work, encourages lateral thinking and

provides a ramework or understanding

why certain conditions have, to date,

resulted in lower than hoped or levels

o CHW retention and motivation.

Understanding country context is key.

The inSCALE countries differ greatly

in their CHW programmes and the

in-country work has been essential

in understanding which innovations

may work and how they can best be

embedded into current structures.

In a multi-country project activity,

timeline differences can be taken

advantage o to allow sk ills sharing

and mentoring across country teams,

by bringing in project staff rom the

secondary country to shadow activities

as they take place in the primary one.

When developing a project with this

many interlinked areas o social and

clinical importance, taking the time to

engage with and discuss ideas with a

variety o proessionals with ex tensive

academic and programme experience

o working with CHWs is beneficial.

Challenges

Although both Uganda and Mozambique

had policies in place to support ICCM

implementation, there were some operational

challenges that delayed implementation,especially since the approach involved

embedding activities into national and

sub-national institutional arrangements. As

a result, activities that were directly linked to

ICCM implementation were behind schedule,

ultimately leading to the implementation o

just one intervent ion arm in Mozambique,

where the delays were more pronounced.

Designing, developing and rolling out two

interventions in two countries simultaneously

is an enormous challenge, the time-consuming

nature o which should not be underestimated.

When working within a field that has a lot o

momentum, the crowding o organisations

working in this field - sometimes with competing/

similar objectives can lead to challenges in

getting buy-in and support rom Ministries

o Health to all project activities. A specific

example is the prolieration o mHealth pilots

in Uganda, where more than 60 projects are

running simultaneously with little involvement

o or coordination by the Ministry o Health.

Lessons learnt

Mozambique: CHW Miguel Tomas packs up his kit

afer completing his ICCM activities or the day

Photo: Ruth Aysis / Malaria Consortium


23/28


24/28

[22 ]

This is now being addressed by the ormation

o a government-led process to create aneHealth ramework to guide and coordinate

project implementation,while ensuring that

government priorities are addressed. This

has led to a delay in get ting approval or

going ahead with project activities.

Working in collaboration with a multi-

disciplinary team (the inSCALE team) rom

many different institutions, particularly at

a distance, can be challenging and requires

substantial upront planning, ace to ace

meetings and a well-organised and proactiveteam. The time that this takes should not be

underestimated when planning a project,

and reliable distance communication

and inormation sharing using sofware

such as Skype conerence calls should be

incorporated rom the beginning. Where

practicable, and as early as possible in the

project lie, time should be built into the

work plan or ace to ace team building

activities and role clarification.

At proposal writing stage or the inSCALE

project it was impossible to anticipate howmuch time would be needed or designing,

developing and piloting the prototype

innovation or testing, which contributed to

a delay in rolling out the interventions. The

design and development were also delayed

by the need or stakeholder buy- in at

national and sub-national levels to assure a

greater chance o successul implementation.

While stakeholder involvement early on in

the project design i s essent ial or buy- in

and understanding o the context specificopportunities and limitations, a challenge with

innovative projects which run over several

years is the ever-evolving policy environment,

where ideas which were seen as uneasible at

one point in time, could be incorporated into

policy and rolled-out a year or two later. While

projects are ofen bound to fixed timelines

rom donors, there is a constant need to juggle

these with being flexible enough to address

the context on the ground.

CHWs learn how to conduct

village health clubs in Uganda

Photo: Paula Valentine / Malaria Consortium

According to the World Health Organisation, eHealth is the combined use o

electronic communication and inormation technology in the health sector. It

includes using inormation and communication technology such as computers,

mobile phones, and satellite communications, or health services and inormation.

eHealth

In recent years, mobile Health, or mHealth, has emerged as an important par t

o eHealth and is defined as the use o mobile communications (such as mobile

phones) or health services. mHealth programmes can serve as the access point

or entering patient data into national health inormation systems, and as remote

inormation tools that provide inormation to healthcare clinics, home providers,

and health workers in the field.

mHealth


25/28


26/28

[24 ]

Malaria Consortium is one o the worlds leading non-

profit organisations specialising in the comprehensive

control o malaria and other communicable diseases

particularly those affecting children under five.

Malaria Consortium works in Arica and Southeast Asia

with communities, government and non-government

agencies, academic institutions, and local and

international organisations, to ensure good evidence

supports delivery o effective services.

Areas o expertise include disease prevention, diagnosis

and treatment; disease control and elimination; health

systems strengthening, research, monitoring and

evaluation, behaviour change communication, and

national and international advocacy.

An area o particular ocus or the organisation is

community level healthcare delivery, particularly through

integrated case management. This is a community based

child survival strategy which aims to deliver lie- saving

interventions or common childhood diseases where

access to health acilities and services are limited or

non-existent. It involves building capacity and support

or community level health workers to be able to

recognise, diagnose, treat and reer children under five

suffering rom the three most common childhood killers:

pneumonia, diarrhoea and malaria. In South Sudan, this

also involves programmes to manage malnutrition.

Malaria Consortium also supports efforts to combat

neglected tropical diseases and is seeking to integrate

NTD management with initiatives or malaria and other

inectious diseases.

With 95 percent o Malaria Consortium staff working in

malaria endemic areas, the organisations local insight

and practical tools gives it the agility to respond to

critical challenges quickly and effectively. Supporters

include international donors, national governments and

oundations. In terms o its work, Malaria Consortium

ocuses on areas with a high incidence o malaria and

communicable diseases or high impact among those

people most vulnerable to these diseases.

www.malariaconsortium.org

About Malaria Consortium

A young mother in Mozambique

waits her turn to see the CHW

Photo: Ruth Ayisi / Malaria Consortium


27/28


28/28

Malaria Consortium

Development House

56-64 Leonard Street

London EC2A 4LT

United Kingdom

Tel: +44 (0)20 7549 0210

Email: [email protected]

www.malariaconsortium.org

Documents

Developing intervention strategies: innovations to improve community health worker motivation and performance