Community Health Worker retention – the example of APEs in Mozambique

1. Community Health Worker retention – the example of APEs in Mozambique Dr. Karin Källander Malaria Consortium www.malariaconsortium.org/inscale

2. Density of health workers and probability of survival

3. 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

4. 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

5. 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

6. 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.

7. 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

8. Retention and performance • Effective 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

10. Miguel Tomas • 2010 – 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.”

11. “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)

12. What can be done to keep Miguel in his role? • Incentives (financial and non-financial) • Supervision • Community awareness and appreciation • Other?

13. Financial incentives • Guidelines 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.

14. Incentives and motivation The 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

15. Types of financial incentives • 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’ • Salaries – paid as long as remain in role • Alternative earning opportunities • Task related allowances or compensation

16. 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).

17. P4P - issues Key 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

18. Regular salaries for CHWs Pros: • 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

19. Non-financial incentives • Little evidence that non-financial incentives are sustainable • Starting 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

20. APE incentives historically Although 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

21. Incentives – APE experiences Financial 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

22. 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 (…)"

23. Supervision • Supervision is a fundamental component of an effective and sustainable APE program • Often focused on top-down strategies and administrative in nature

24. Supervision – APE reality • Irregular (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)

25. Supportive supervision • Supportive supervision approaches are needed: • define clear objectives and expectations among CHW and program managers • effectively monitor performance -- both successes and challenges • help interpret available data • offer relevant and appropriate education for all parties • assist in planning and problem solving • aim 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

26. APE requests for supervision • Supervision every two months • Increased 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

27. 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

28. “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

30. 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

31. Incentives – Possibilities (2) Non-financial incentives • Promoting positive identity – branding of equipment (t-shirts, boxes, certificates etc) • Promote early successes achieved by APEs to APEs themselves and to the wider community • Establish 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

32. Supervision – promising approaches • Group supervision more effective than one-to-one for group identity/team spirit • The role of technology for remote supervision • Mobile phones • Simple laptops • Targeted supervision for weak performers • Peer supervision and mentoring to complement HW supervision

33. Community involvement and appreciation - possibilities • Fostering 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

34. 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.

35. Muito Obrigada!!