Health worker motivation strategies for engagement

In many countries, Community Health Workers (CHWs) provide important health services to their communities and serve as a link to the formal health system.

One significant challenge CHW programs face is finding ways to engage and motivate CHWs to continue to provide quality services to their communities over time.

Even when digital decision support tools are introduced to improve CHW competence and confidence in delivering care, CHWs, especially those in rural areas, face challenges of isolation, limited support and receive limited performance-related feedback.

In multiple programs which D-tree International supports with partners, CHWs use digital tools to guide them through a visit with a client. Using logic, the mobile app provides a user friendly dialogue which is tailored to the needs of the client and supports the CHW to provide appropriate advice, accurate diagnoses and timely referrals. At the end of each visit, the CHW schedules a date for a follow up visit which varies in length based on the outcome of the visit.

In many programs, CHWs receive a small stipend (approximately USD 10-15 per month) for their services.

In addition to supporting high quality care delivery, the digital system captures data as a by-product of these visits which we can leverage to track activity, measure performance metrics and provide constructive feedback to the CHW. We can also use data to implement pay for performance schemes which link the amount of CHW stipend to set performance targets each month.

For example, in northwest Tanzania, CHWs providing family planning services are tasked with registering 10 new clients each month. At the end of each visit, the CHW schedules a follow up visit for a specific date which varies in length based on the outcome of the visit. CHWs are encouraged to complete at least 75% of these follow up visits as a way of providing consistent, continuous care. We can develop our data structures within the mobile app to capture data about the number of new clients registered, the number of follow up visits scheduled, and the number of follow up visits completed in a given month. We then create a sliding scale for stipends based on a CHWs progress towards these targets each month.

To fully support CHWs, we use this data in several ways. First, CHWs can view their monthly activity and calculated stipend on their device through a web tab which is updated in real time.

CHW supervisors can view performance data for all of their CHWs at any time and use this information to provide performance-based feedback during supervisory phone calls and in-person meetings. Supervisors can easily identify CHWs who are not on track to meet their targets and follow up to provide additional support. Conversely, supervisors can congratulate those who achieve their targets and provide ongoing encouragement.

The program dashboard also contains CHW activity tracking and pay for performance tables which allow program managers and the Ministry of Health to monitor activity. At the aggregate level, one can easily track overall performance over time to monitor trends.

Aggregate CHW performance tracking over time
Performance tracking of CHW groups for a particular month

At the individual level, one can review CHW performance each month and track stipends to be sent out. Mobile money APIs make it possible to automatically send CHW stipends - based on the pay for performance calculations - each month.

Individual performance tracking

In November 2014, 60 CHWs in Shinyanga District Council, who had previously been delivering family planning services using a paper-based system, were trained to use the mobile application. The pay for performance system, along with rigorous data monitoring and feedback to CHWs, was also introduced at this time. The impact of this system on CHW performance has been significant. Compared to the paper based system, which included the same performance targets and the same stipend, CHW performance with the digital health system increased dramatically. On average, we have seen a 5-fold increase in the number of monthly registrations and a 15-fold increase in follow-up visits. This level of performance has bee maintained for the past 3 years.

CHW performance before and after the introduction of the digital health system and pay for performance program
5-fold increase in client registrations
15-fold increase in follow-up visits
Increased performance sustained for 3 years and counting...

D-tree has now institutionalized this methodology and uses pay for performance schemes in multiple programs for family planning, maternal and child health. In each program we have seen similar sustained improvements in health worker performance.

D-tree International


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