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. There was an additional focus on using these sources to identify areas of legitimate need with genuine potential for innovation.
The inSCALE project countries differ greatly in their community health worker (CHW) programmes, making this landscape analysis essential to understanding which innovations may work and how to embed them into current structures. One major difference identified, for example, was CHW coverage. In Mozambique, one CHW covers approximately 2,000 community members who live 8-25km from a health facility, whereas Ugandan CHWs should be present in all villages and typically cover between 250 and 500 people. Such a variation would affect the feasibility of some innovations, so it was important that adjustments were made to the design of the intervention packages for each country.
Click here to access the reports from the landscape analysis.
Having conducted the landscape analysis, potential intervention methods and innovations were narrowed down. The formative research stage then helped fine-tune the activities that had been identified by gauging the views of the community health workers (CHWs), their supervisors, district officials and key programme implementers, as well as caregivers, heads of households and traditional community leaders, on the following:
The formative research in Mozambique found that communities use the CHWs, think their work is important and respect them; a supportive relationship that is valued by the CHWs. Therefore innovation design in Mozambique should highlight community support and use terminology meaningful to CHWs, such as “reputation, respect and recognition”.
Formative research findings in Uganda found that status and community standing is important to CHWs; yet many feel that their work and aims are not well understood in their communities. Therefore in Uganda, innovation design should aim at increasing CHW standing and status to improve motivation by, for example, encouraging a higher level of involvement by community leaders in CHW work.
In both Uganda and Mozambique, CHWs find positive feedback and acknowledgement of their work motivating. They value performance focused supervision as this provides them with knowledge to improve how they serve their community. However, health facility supervision is found to be sporadic due to work loads and transport costs. For both countries, conducting performance based supervision over the phone may reduce travel needs and make supervision more efficient.
Click here to access the reports from the formative research.
A process evaluation of this intervention was carried out in Mozambique in mid-2014. Preliminary results show that 68 percent of community health workers in Mozambique (locally known as agentes polivalentes elementares or APEs) state that they always use the inSCALE APE CommCare application in their work, and many state that it helps them to remember the symptoms to look for. The three most preferred aspects of the inSCALE APE CommCare application were the job aid for newborns, children and pregnant women; improved respiratory rate timer; and treatment and dosing instructions. The inSCALE APE CommCare application is also seen to enhance community perception and legitimacy of APEs. It provides APEs with opportunities to acquire new skills and increases level of support from their supervisors, both of which are key drivers to motivation. Medicine stock data delivered through weekly reports is seen as useful to health facility supervisors, and critical for addressing commodity gaps. An impact and cost-effectiveness evaluation is planned for mid-2015.
Preliminary results for Uganda will be available shortly.
Understanding country context is key. The inSCALE countries differ greatly in their community health worker (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.
When working within a field that has a lot of momentum, the “crowding” of organisations working in this field - sometimes with competing/ similar objectives – can lead to challenges in getting buy-in and support from Ministries of Health to all project activities. A specific example is the proliferation of mobile health (mHealth) pilots in Uganda, where more than 60 projects are running simultaneously with little involvement of or coordination by the Ministry of Health. This is now being addressed by the formation of a government-led process to create an eHealth framework to guide and coordinate project implementation, while ensuring that government priorities are addressed.
While stakeholder involvement early on in the project design is essential for buy-in and understanding of the context specific opportunities and limitations, a challenge with innovative projects which run over several years is the ever-evolving policy environment, where ideas which were seen as unfeasible at one point in time, could be incorporated into policy and rolled-out a year or two later. While projects are often bound to fixed timelines from donors, there is a constant need to juggle these with being flexible enough to address the context on the ground.
For a more detailed summary of the landscape analysis, formative research and lesson learning, please read our learning paper ‘Developing Intervention Strategies’, which is also available in Portuguese ‘Desenvolvimento de Estratégias de intervenção’.