Implementing mHealth Solutions To Improve Community Health Worker Motivation and Performance

“Integrated community case management (iCCM) is an approach whereby community health workers (CHWs) are trained to identify and treat pneumonia, diarrhoea and malaria in children under five years, as well as to refer severely ill cases to the nearest health facility.”

The Malaria Consortium’s Innovations at Scale for Community Access and Lasting Effects (inSCALE) project has been working to scale up quality integrated community case management programmes to improve child health in Uganda and Mozambique. This Learning Paper details the process of establishing mobile health (mHealth) interventions in these two countries to improve community health workers’ (CHWs) motivation and performance, as part of the ‘technology intervention’ arm of the inSCALE project. The technology intervention was complemented by a community intervention to improve CHW performance through the formation of Village Health Clubs (see Related Summary below).

Overall, the aim of the project was to demonstrate that government-led iCCM programmes in two African countries could be scaled up while maintaining quality of care by addressing the barriers to iCCM implementation, namely the lack of supportive supervision and CHW motivation. The objective of the technology intervention, as described in this brief, was to promote CHW learning and support with the use of low-cost technology involving the development of tools and applications for mobile phones, to increase CHWs’ feeling of connectedness to the wider health system. The mobile phone software also promotes CHW motivation and performance through job aids that support decision-making, data submission, and performance-related feedback.

The report describes the technology intervention and development of the mobile phone software and feedback systems in both countries, which were based on inSCALE’s formative research. Because CHWs in Uganda and Mozambique have distinct needs and work in contrasting settings in terms of their caseload, training, and coverage, different intervention packages were implemented in the two countries. The intervention packages are described in the brief looking at: the types of phones used; the provision and use of solar chargers; receipt of motivational messages on the phone; the provision of job aids on the phones, such as respiratory rate timers to detect pneumonia symptoms and audiovisual guides to guide consultations; competency checklists for supervisors; data submission processes; and performance alert processes to alert to problems and strengths in the data submitted by CHWs.  

The brief also describes in detail how the implementation of the invention unfolded in each country. It looks at, among other things, the process of stakeholder discussions, the development of the soft ware, the development and testing of job aids for CHWs, the training of CHWs (1,277 in Uganda and 132 in Mozambique) using the training-of-trainers approach, and the series of follow-up activities which ensured maximised and correct use of the inSCALE mobile systems.

In terms of the uptake of the intervention, the report also reports on project outcomes based on regular progress reviews and process evaluations in both countries. These showed “increased communication between CHWs, their peers and supervisors, and that data submission and receiving feedback messages were highly motivating to CHWs. However, at full implementation strength, the reporting rate rarely reached more than 50 percent in Uganda. In Mozambique, where there were fewer technical challenges which were more quickly resolved, the reporting rate remained at 60-70 percent during full implementation strength.”

The lessons learned are highlighted as they relate to the key aims of the project which were: improved CHW status and standing; improved CHW support and supervision; increased CHW feeling of connectedness to the health system; increased CHW performance and motivation; and increased access to and use of appropriate treatment. For example, related to increased performance and motivation, in Uganda findings showed that VHTs improved their performance through more correct diagnosis of malaria and diarrhoea using the phone timers, refresher training SMS messages, and phone consultations with supervisors and other village health teams. In Mozambique, findings showed that the inSCALE phones and the visual job aids also provided CHWs with opportunities to acquire new skills, and many used the diagnosis and treatment guide, which improved their performance and validated their knowledge among caregivers.

Looking at some of the challenges, the brief states that the majority of the challenges faced owed to software and network issues, but they also included hardware issues and medicine stock-outs. To address these challenges, the brief offers a list of recommendations, which include contracting software partners with experience in mHealth initiatives, using an easily customisable platform, and choosing tailor-made network provider packages to retain control of service adjustments.

Moving forward, the Malaria Consortium continues to engage with mHealth partners in Uganda to determine how components of the inSCALE technology arm can be incorporated into other systems. The organisation is also working with partners in Mozambique to scale up the inSCALE technology intervention, and is in the process of handing over the system to the Ministry of Health.