Developing Intervention Strategies to Improve Community Health Worker Motivation and Performance

This 28-page learning paper describes Malaria Consortium’s experience with Integrated Community Case Management (ICCM) in malaria prevention and treatment in Mozambique and Uganda. ICCM is an approach where community-based health workers are trained to identify, treat, and refer complex cases malaria (and other diseases) in children. In partnership with the London School of Hygiene and Tropical Medicine and University College London, Malaria Consortium received funding from the Bill & Melinda Gates Foundation to manage the Innovations at Scale for Supporting Community Access and Lasting Effects (inSCALE) project to identify and test innovative solutions that can facilitate sustainable scale up of ICCM in African countries. This paper summarises the process adopted by inSCALE for identifying the barriers to CHW motivation and performance in Uganda and Mozambique and documents identified solutions to these challenges.
According to the learning paper, the three main implementation barriers were identified as the following:

• Minimally trained CHWs need regular, supportive supervision to operate effectively; yet distances to health facilities and district offices and lack of transportation, coupled with poorly developed management information systems, present a continuous challenge to implementation of effective supervision.
• Motivation – through remuneration or otherwise – of CHWs is a critical barrier in most countries. Many governments are reluctant to allocate funds and create thousands of new civil servant posts, yet lack alternative approaches to motivate CHWs to keep their health provision services effective and operational.
• Documentation of programme implementation processes and results, and sharing of solutions with districts about to start implementation, is scarce, leading to continuous and significant waste of time and resources.

At the beginning of the inSCALE project a variety of reviews and consultations took place to ensure interventions designed drew on experience from previous work and appropriate theory. Based on the theoretical findings, the inSCALE team began the extensive process of narrowing down potential intervention methods and innovations. Some were identified as best practices and added to the 'resource bank' while others were sorted in to 'best bets' for the Uganda and Mozambique contexts. Through an extensive process of consultation, a series of interventions were planned, grouped into two clusters: a technology arm and a community-based arm. At the conclusion of the theory and research stage, the inSCALE team had defined two intervention strategies for influencing CHW motivation and retention in two different ways. With a final list of 15 potential activities across the two intervention packages in two countries, formative research was used to fine-tune the activities by gauging the views of the CHWs, their supervisors, district officials, and key programme implementers, as well as caregivers, heads of households, and traditional community leaders.

The community based approach in Uganda is involving 800 CHWs across five districts. The first step in the training cascade was to train 39 development officers, health facility in-charges, and health assistants, who in turn are training two ICCM CHWs in each village as village health club facilitators with initial practical guidance and support from 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 follow up and supportive supervision visits to CHWs to assess their core competencies in delivering ICCM, thus ensuring smooth set up and running of the village health clubs. In both Uganda and Mozambique (Mozambique will only carry out the technology arm), the technology arm will include training CHWs to use mobile phones to assist their work in the community, and trainers will carry out follow up and supportive supervision visits to ensure that appropriate, quality care is delivered and that mobile phones are being used appropriately and to maximum effect.

During the first 12 months, the project will assess how effective 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 remedial action is necessary and feasible, and explain how and why the interventions work or do not work.
Lessons learnt about successful strategies include the following:

• 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 useful to garner ideas and can make an important contribution to decision making. Similarly, literature reviews from ‘off target’ areas such as the business world can offer a fresh perspective and provide useful insights and ideas.
• Early on in the project, mobile phone numbers for the majority of the CHWs (over 7,000) trained in the nine districts in Uganda were collected, which proved a very useful resource for understanding CHWs access to mobile phone networks and for pre-testing SMS messages. A locally established call centre carried out phone interviews with CHWs – an immensely time-saving approach replacing the need for numerous field visits.
• Taking a theoretical view of motivation and retention helps identify innovations and their potential effect, particularly when evidence is lacking. It also helps understand how innovations may work, encourages lateral thinking and provides a framework for understanding why certain conditions have, to date, resulted in lower than hoped for levels of 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 of to allow skills sharing and mentoring across country teams, by bringing in project staff from the ‘secondary’ country to shadow activities as they take place in the ‘primary’ one.
• When developing a project with this many interlinked areas of social and clinical importance, taking the time to engage with and discuss ideas with a variety of professionals with extensive academic and programme experience of working with CHWs is beneficial.

According to the learning paper, 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 of just one intervention 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 of which should not be underestimated.