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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:
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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
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[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
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[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
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[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
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
ITERATURE REVIEWS THEORYEXPERT CONSULTATIONSBEST
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
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[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
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[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
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[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
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[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
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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 ]
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[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
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[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
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[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.
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[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
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MOTIVATION
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ISION
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ISION
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TECHNOLOGY
TECHNOLO
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[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
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[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
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[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
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[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
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[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
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[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
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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
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