Community Health Worker retention –
the example of APEs in Mozambique
Dr. Karin Källander
Malaria Consortium
www.malariaconsortium.org/inscale
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 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
Policy
Country
health system
- investment
Culture and
community
context
- Community
attitude to
health & illness
Program structure ,
culture & environment
-incl strategy &
resources
- Supervision
- Incentives
- Community
involvement
Motivation to perform
Patent & community
expectations of CHWs
- Relationship
- Encounter expectations
- Treatments vs.
prevention
Individual
- Needs satisfaction
- Self efficacy
- Identity
- Program comittment &
goals
- Outcome expectancies
- Intentions
Environmental
CHW characteristics
- Demographics
- Knowledge / education
- Expectations
- Workload
- Geography
- Justice / equity
- Job security
- Management /
supervision support
- Respect
Performance
Retention
Experience
of
outcomes
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.”
 “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 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.
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
Types of financial incentives
1. 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 - 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
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
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
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
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
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 (…)"
Supervision
 Supervision is a fundamental component of
an effective and sustainable APE program
 Often focused on top-down strategies and
administrative in nature
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)
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
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
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
Culture and
community
context
- Community
attitude to
health & illness
Program structure , culture &
environment
-incl strategy & resources
• Supervision
• Incentives
• Community involvement
Motivation to perform
Patent & community
expectations of CHWs
- Relationship
- Encounter expectations
- Treatments vs.
prevention
Individual
- Needs satisfaction
- Self efficacy
- Identity
- Program comittment &
goals
- Outcome expectancies
- Intentions
Environmental
CHW characteristics
- Demographics
- Knowledge / education
- Expectations
- Workload
- Geography
- Justice / equity
- Job security
- Management /
supervision support
- Respect
Performance
Retention
Experience
of
outcomes
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 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
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
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
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!!