Abstract
BackgroundIf trained, equipped and utilised, community health workers (CHWs) delivering integrated community case management for sick children can potentially reduce child deaths by 60%. However, it is essential to maintain CHW motivation and performance. The inSCALE project aims to evaluate, using a cluster randomised controlled trial, the effect of interventions to increase CHW supervision and performance on the coverage of appropriate treatment for children with diarrhoea, pneumonia and malaria.Methods/DesignParticipatory methods were used to identify best practices and innovative solutions. Quantitative community based baseline surveys were conducted to allow restricted randomisation of clusters into intervention and control arms. Individual informed consent was obtained from all respondents. Following formative research and stakeholder consultations, two intervention packages were developed in Uganda and one in Mozambique. In Uganda, approximately 3,500 CHWs in 39 clusters were randomised into a mobile health (mHealth) arm, a participatory community engagement arm and a control arm. In Mozambique, 275 CHWs in 12 clusters were randomised into a mHealth arm and a control arm. The mHealth interventions encompass three components: 1) free phone communication between users; 2) data submission using phones with automated feedback, messages to supervisors for targeted supervision, and online data access for district statisticians; and 3) motivational messages. The community engagement arm in Uganda established village health clubs seeking to 1) improve the status and standing of CHWs, 2) increase demand for health services and 3) communicate that CHWs’ work is important. Process evaluation was conducted after 10 months and end-line surveys will establish impact after 12 months in Uganda and 18 months in Mozambique. Main outcomes include proportion of sick children appropriately treated, CHW performance and motivation, and cost effectiveness of interventions.DiscussionStudy strengths include a user-centred design to the innovations, while weaknesses include the lack of a robust measurement of coverage of appropriate treatment. Evidence of cost-effective innovations that increase motivation and performance of CHWs can potentially increase sustainable coverage of iCCM at scale.Trial registration(identifier NCT01972321) on 22 April 22 2013
Highlights
This paper presents a protocol for a cluster randomised controlled trial conducted under the inSCALE project (Innovations at Scale for Community Access and Lasting Effects). inSCALE aims to enhance the motivation and performance of community health worker (CHW) in order to increase the coverage of children who receive appropriate treatment for diarrhoea, pneumonia and malaria in Uganda and Mozambique
In 2004, after the rebel war, United Nations Children’s Fund (UNICEF) supported the Ministry of Health (MoH) to pilot the implementation of home-based care of children with diarrhoea, pneumonia and malaria in Northern Uganda using oral rehydration solution (ORS), cotrimoxazole and artemether-lumefantrine (Coartem; Novartis)
For child health interventions like Integrated community case management (iCCM) to have impact when implemented at scale, it is crucial that cost-effective strategies that improve performance and motivation of CHWs are identified and evaluated in a ‘real-life’ health systems context
Summary
If trained, equipped and utilised, community health workers (CHWs) delivering integrated community case management for sick children can potentially reduce child deaths by 60%. Child mortality has been reduced significantly in a number of African countries Preventable illnesses such as diarrhoea, pneumonia and malaria are still claiming almost 2 million lives in newborns, infants and children under five years of age [1]. As a way of increasing access to treatment for sick children, several African countries are investing in community health workers (CHWs) as a cost-effective way of extending health services to people living beyond the reach of the health facilities. If properly trained, equipped and utilised, CHWs have the potential to reduce child deaths substantially by increasing access to timely, appropriate and affordable treatment for poor and rural populations [4]
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