Project overview

The Innovations at Scale for Community Access and Lasting Effects (inSCALE) project was a seven-year multi-country study conducted in Uganda (Midwestern region) and Mozambique (Inhambane province). The inSCALE project aimed to demonstrate that government-led integrated community case management (iCCM) programmes could be scaled up while maintaining quality of care by addressing the common barriers to iCCM implementation  emphasised in the literature. This was to be achieved by:

1. Identifying innovative solutions with potential to increase community health worker (CHW) motivation and supportive supervision;
2. Assessing feasibility and acceptability of these innovations among community members, CHWs, facility-based health workers and subnational and national health authorities;
3. Evaluating the impact of the selected interventions on CHW performance, motivation and retention and on the coverage of appropriate treatment for children with diarrhoea, malaria and pneumonia;
4. Costing the interventions and investigating their potential cost-effectiveness;
5. Promoting the implementation and spread of iCCM by sharing with the Ministry of Health (MoH), subnational health authorities and stakeholders the experiences and findings that improve coverage and quality of iCCM.

The inSCALE project conducted extensive formative research to develop two intervention packages that were evaluated through cluster randomised controlled trials. The two interventions were:

• The technology intervention: This approach used low-cost technology to promote learning and increase CHWs’ confidence and connectedness to the wider health system through the development of tools and applications for mobile phones. The mobile phones used in the study were selected based on the county context, with smartphones used in Mozambique and feature phones in Uganda. The mobile phone software inSCALE developed was intended to enhance CHW motivation and performance through job aids that support decision-making (Mozambique only), data submission and performance-related feedback, as well as closed user groups to allow free calls among CHWs and their supervisors.
• The community intervention: This intended to promote CHWs as key village health assets to improve motivation and performance. This community mobilisation approach used the formation of Village Health Clubs, established on five key pillars and focused on a learning and action cycle, as a platform for participatory and locally owned identification of health problems and solutions. This intervention was implemented in Uganda only, since the local CHW strategy in Mozambique already incorporates substantial community components.