Dr. Karin Källander Malaria Consortium www.malariaconsortium.org/insca le Community Health Worker retention – the example of APEs in Mozambique
Feb 03, 2016
Dr. Karin Källander
Malaria Consortium
www.malariaconsortium.org/inscale
Community Health Worker retention – the example of APEs in Mozambique
Density of health workers and probability of survival
Integrated Community Case Management - iCCM
CHW diagnosis, treatment and referral of diarrhoea, malaria and pneumonia (and newborns)
ICCM programs can prevent 60% of under-five mortality
Well-trained, resourced and motivated CHWs is potentially a high impact cost-effective intervention that complement overburdened health systems
In Mozambique, the APE program has potential to cut under-five mortality by almost 50% with an associated per capita cost of US1.18/year
APE and ICCM Strategy Historically:
APE program was poorly resourced but successfully implemented (pneumonia was not included)
Grounded in Socialism and characterized by community involvement, local leadership commitment and voluntarism
Affected by 16 years of war
Now:
A priority for the Mozambican Government
In revitalization process: new training curriculum based on ICCM, new incentives scheme and data record tools
Malaria Consortium and iCCM
Several countries including Mocambique and Uganda are scaling up iCCM
Implementation has been constrained by poor supervision and motivation of CHWs (APEs)
BMGF grant to understand performance and retention of CHWs, and test solutions for successful implementation of iCCM at scale
Building on the CIDA implementation in Uganda and Mozambique
inSCALE project – Innovations at Scale for Community Access and Lasting Effects
To demonstrate that government led iCCM programs in Mozambique and Uganda can be rapidly scaled-up with quality if critical limitations such as the motivation and retention of CHWs are addressed, leading to a sustained increase in the proportion of sick children receiving appropriate treatment.
Methods
Literature reviews – theory, global experiences and innovations
Global stakeholder interviews – best practices, possible innovations
National stakeholder interviews and FGDs - in-country experience, context specific challenges, success stories and local solutions
Retention and performanceEffective retention:
The choice to stay in the role with a motivation to perform.
Functional/dysfunctional turnover
Retention linked to worker satisfaction:
Availability of necessary tools and resources
Stability and predictability of income (absence of need for “survival strategies”)
Performance linked to motivation:
Working context (skills, processes, work environment)
All are context specific
Policy Country health system- investment
Program structure , culture & environment-incl strategy & resources - Supervision- Incentives- Community
involvement
Patent & community expectations of CHWs- Relationship- Encounter expectations- Treatments vs. prevention
Culture and community context- Community attitude to health & illness
CHW characteristics- Demographics- Knowledge / education- Expectations
PerformanceExperience
of outcomes
Motivation to perform
Individual- Needs satisfaction- Self efficacy- Identity- Program comittment & goals- Outcome expectancies- Intentions
Environmental- Workload - Geography- Justice / equity- Job security- Management / supervision support- Respect
Retention
Miguel Tomas2010 – Mechanic
2011 – APE
Nominated by his father
“He is a respected community member, able to read and write, and is between 18 and 40 years. He was also prepared to work without pay.”
“Although it’s only mid-morning, I have had 15 consultations already. I started work when the first person arrived at my home at 5 am. After 10 am I will carry out home visits to complete disease prevention work and treat anyone who is sick.”
“I like this job. I’m helping my community to make our life better.” Miguel Tomas, Agente Polivante Elementar (APE)
What can be done to keep Miguel in his role?
Incentives (financial and non-financial)
Supervision
Community awareness and appreciation
Other?
Financial incentivesGuidelines from WHO suggest payment is necessary
for the long term sustainability of CHWs
Moral argument for providing CHWs with financial compensation for their labour and if they are not, a rationale should be developed and communicated
There is increasing demand for payment from CHWs
Despite theoretical reservations, programs and governments are implementing. Therefore represents a topical and needed research opportunity.
Incentives and motivationThe potential for a financial incentive to motivate
depends on:
The value of the financial incentive to the CHW – degree to which is satisfies need (survival, autonomy)
CHW perception of the link between performance and reward
Understanding of how this will be measured and monitored
The perceived fairness of the payment
Reliability of the payment
Types of financial incentives1. Pay for performance – P4P (results based
financing)
‘the transfer of money or material goods conditional on taking a measurable action or achieving a predetermined performance target’
2. Salaries – paid as long as remain in role
3. Alternative earning opportunities
4. Task related allowances or compensation
P4P‘You will get what you pay for so make sure you pay for
what you want to get’
Limited examples of P4P programs that have specifically targeted CHWs
In low income settings performance based payment can create uncertainty and negative perceptions of job security
Limited available evidence indicates that when properly designed and implemented P4P can have a positive effect on health outcomes
A recent meta analysis of P4P studies in high income countries found 5% improvement due to P4P use but with a lot of variation depending on the measure and program (Van Herck et al, 2010).
P4P - issuesKey considerations for design and implementation include:
Worker and community perceptions
Financing is best managed by local government structures as is the case in decentralised Mozambique
Slow implementation and piloting recommended ahead of national scale up
Performance measures and targets should be developed in consultation with CHWs and be in areas they have a high degree of control over. They should be set at a level that is achievable with reasonable effort and is equitable across workers and regions
Success hinges on accurate validation processes and HMIS as well as timely payments
Regular salaries for CHWsPros:
Likely to impact retention (but not performance) (functional or mainly dysfunctional retention?)
By keeping CHW in role may provide opportunity for satisfaction and increased performance
Cons:
May oblige CHWs to work longer hours reducing opportunities for other income generation
Impact on retention may be linked to pay growth rather than pay per se
May lead to perception of being a government employee rather than a community member
Non-financial incentivesLittle evidence that non-financial incentives are
sustainableStarting point: impact possible or likely only in
absence of need for ‘survival strategies’The likelihood a worker will be motivated by a
non-financial incentive linked to attainment of personal goals
Key areas for non-financial incentive:Refresher training / supervision
Career progression and advancement
Role clarity
Relationship with the community
APE incentives historicallyAlthough program is almost 30 years old:
Historically the APE were incentivized by goods like soaps, agricultural products offered by the community, building of community heath post and other local ideas.
Because of socio cultural and economic dynamic and worsening poverty gradually this kind of incentives may no longer satisfy the APE expectations.
New incentives policy involves monthly subsidies
Incentives – APE experiencesFinancial incentives were promised but are irregular or non-existing
Expectation of receiving a wage motivate APEs to continue to work – short term?
Lack of money for transport to deliver data records and collect Kit C
Non-financial incentives include mainly job tools:
Continuous training, uniforms, T-shirts, caps, and briefcases with the program logo and ID cards were stated to be very encouraging, especially because it would mean recognition of the work in the communities
FGDs Homoine
“They don't pay us wage but every month we are forced go and deliver the monthly data and to collect the KIT C from the district, which is very far. To pay for the trip I always have to borrow money from my neighbours. To get there I have to take 3 buses and the trip takes a long time. Sometimes I have to wait in the health unit for up to 15 hours and I lose the chance of getting a bus to return and I am forced to arrange a place to sleep. I am paying all those expenses alone. This isn't fair (…)"
SupervisionSupervision is a fundamental component
of an effective and sustainable APE program
Often focused on top-down strategies and
administrative in nature
Supervision – APE realityIrregular (2-3 times a year) and “policing” rather
than supportive, with little focus on motivational support and problem solving for performance enhancement.
Weak or non-existent relationship with health professionals.
"In spite of being positive I feel that the supervision visit besides being irregular, doesn't include all the components of our work and it lasts for a short time. It would be better if they to observed how I serve the people.” (Muiambo 2010)
Supportive supervisionSupportive supervision approaches are needed:
define clear objectives and expectations among CHW and program managers
effectively monitor performance -- both successes and challenges
help interpret available dataoffer relevant and appropriate education for all partiesassist in planning and problem solvingaim to strengthen community relationships and support
their full engagement and participation in program planning and service delivery
foster the perception of being a valued part of the health system
APE requests for supervisionSupervision every two monthsIncreased duration of each supervision session Include observation of APE actions, such as
prescription of medicines and the way they promote messages and health education
Community leaders, religious leaders and teachers to participate in supervision activities, such as completion of registers and verification of expiry dates of the medicines
Community involvement and appreciation
APE perception on the importance of their work in improving health in the communities is key to motivation
APEs do not understand the usefulness of the data collated and rarely receive feedback on data sent
Communities recognize and respect the work of APEs but there is little involvement of community leaders and members to support APE activities
“Lots of people have died here because they could not get to hospital in time” Tomas Laquico, community leader
“Before it used to take me 2 hrs by bike to get to the hospital and then I would sometimes wait 2 hrs before being seen. By contrast, this time it was a 20-minute walk to see Miguel.” Gilda Nassone, Mother of Toucha
Policy Country health system- investment
Program structure , culture & environment-incl strategy & resources
• Supervision• Incentives • Community involvement
Patent & community expectations of CHWs- Relationship- Encounter expectations- Treatments vs. prevention
Culture and community context- Community attitude to health & illness
CHW characteristics- Demographics- Knowledge / education- Expectations
PerformanceExperience
of outcomes
Motivation to perform
Individual- Needs satisfaction- Self efficacy- Identity- Program comittment & goals- Outcome expectancies- Intentions
Environmental- Workload - Geography- Justice / equity- Job security- Management / supervision support- Respect
Retention
Incentives – possibilities (1)Financial incentives:Assess community acceptability of the APE role when voluntary vs. remunerated and to benchmark rates against other comparable programs. Introduce drug revolving funds to collectives of APEs.Facilitated income generation – vaccination programs Assist APEs to establish their own business in a way that is manageable alongside their duties
Incentives – Possibilities (2)Non-financial incentivesPromoting positive identity – branding of equipment (t-shirts, boxes, certificates etc)Promote early successes achieved by APEs to APEs themselves and to the wider communityEstablish a national day for CHWs where, through multiple media channels, awareness of their role is raised and appreciation encouraged Create professional pathways for exceptional performers
Supervision – promising approachesGroup supervision more effective than one-to-one
for group identity/team spiritThe role of technology for remote supervision
Mobile phones Simple laptops
Targeted supervision for weak performersPeer supervision and mentoring to complement
HW supervision
Community involvement and appreciation - possibilitiesFostering links between APEs and established
groups in the community (youth groups, churches)
Establish community health committees comprised of community leaders and other community members to oversee the program.
Community level meetings to promote the APE role, feed back information and lessons and promote accountability of APE to the community.
Utilising the health information collected by APE to promote the role of the APE and the effectiveness of their activities
Conclusion Incentives (regular financial plus non-financial),
supervision and community involvement are key to effective retention of APEs
Improvement in all three areas is necessary for retention of the recently trained APEs.
Great potential to develop and test innovative solutions in all three areas which are feasible, acceptable and scalable.
Next steps – “pile sort exercise” where we do a short listing of innovations with stakeholders.
Muito Obrigada!!