BackgroundCommunity health workers (CHWs) in Mozambique (known as Agentes Polivalentes Elementares (APEs)) are key actors in providing health services in rural communities. Supervision of CHWs has been shown to improve their work, although details of how it is implemented are scarce. In Mozambique, APE supervision structures and scope of work are clearly outlined in policy and rely on supervisors at the health facility of reference. The aim of this study was to understand how and which aspects of supervision impact on APE motivation and programme implementation.MethodsQualitative research methodologies were used. Twenty-nine in-depth interviews were conducted to capture experiences and perceptions of purposefully selected participants. These included APEs, health facility supervisors, district APE supervisors and community leaders. Interviews were recorded, translated and transcribed, prior to the development of a thematic framework.ResultsSupervision was structured as dictated by policy but in practice was irregular and infrequent, which participants identified as affecting APE’s motivation. When it did occur, supervision was felt to focus more on fault-finding than being supportive in nature and did not address all areas of APE’s work – factors that APEs identified as demotivating. Supervisors, in turn, felt unsupported and felt this negatively impacted performance. They had a high workload in health facilities, where they had multiple roles, including provision of health services, taking care of administrative issues and supervising APEs in communities. A lack of resources for supervision activities was identified, and supervisors felt caught up in administrative issues around APE allowances that they were unable to solve. Many supervisors were not trained in providing supportive supervision. Community governance and accountability mechanisms were only partially able to fill the gaps left by the supervision provided by the health system.ConclusionThe findings indicate the need for an improved supervision system to enhance support and motivation and ultimately performance of APEs. Our study found disconnections between the APE programme policy and its implementation, with gaps in skills, training and support of supervisors leading to sub-optimal supervision. Improved methods of supervision could be implemented including those that maximize the opportunities during face-to-face meetings and through community-monitoring mechanisms.

Supportive supervision is an important element of community health worker (CHW) programmes and is believed to improve CHW motivation and performance. A group supervision intervention, which included training and mentorship of supervisors, was implemented in Ethiopia, Kenya, Malawi and Mozambique. In three of the countries, this was combined with individual and/or peer supervision. A mixed-methods implementation study was conducted to assess the effect of the supervision intervention on CHWs’ perceptions of supervision and CHW motivation-related outcomes. In total, 153 in-depth interviews were conducted with CHWs, their supervisors and managers. In addition, questionnaires assessing perceived supervision and motivation-related outcomes (organizational and community commitment, job satisfaction and conscientiousness) were administered to a total of 278 CHWs pre- and post-intervention, and again after 1 year. Interview transcripts were thematically analysed using a coding framework. Changes in perceived supervision and motivation-related outcomes were assessed using Friedman’s ANOVA and post hoc Wilcoxon signed-rank tests. Interview participants reported that the supervision intervention improved CHW motivation. In contrast, the quantitative survey found no significant changes for measures of perceived supervision and inconsistent changes in motivation-related outcomes. With regard to the process of supervision, the problem-solving focus, the sense of joint responsibilities and team work, cross-learning and skill sharing, as well as the facilitating and coaching role of the supervisor, were valued. The empowerment and participation of supervisees in decision making also emerged in the analysis, albeit to a lesser extent. Although qualitative and quantitative findings differed, which could be related to the slightly different focus of methods used and a ‘ceiling effect’ limiting the detection of observable differences from the survey, the study suggests that there is potential for integrating supportive group supervision models in CHW programmes. A combination of group with individual or peer supervision, preferably accompanied with methods that assess CHW performance and corresponding feedback systems, could yield improved motivation and performance.

BackgroundCommunity health workers (CHWs) are increasingly being used in low-income countries to address human resources shortages, yet there remain few effective, evidence-based strategies for addressing the enduring programmatic constraints of worker motivation, retention and performance. This paper describes how two interventions were designed by the Innovations at Scale for Community Access and Lasting Effects (inSCALE) project to address these constraints in Uganda and Mozambique drawing on behavioural theory and formative research results.MethodsA review of the work motivation and CHW motivation literature—incorporating influences on retention and performance—was conducted on articles sourced through electronic web searches. Formative research with a focus on the barriers and facilitators to CHW motivation, retention and performance was conducted with community health workers and key stakeholders in Uganda and Mozambique. An analytical induction approach to the thematic analysis of transcripts from 98 in-depth interviews and 26 focus group discussions was adopted across the country settings.ResultsFrom the theoretical review, it was determined that the interventions should promote CHWs as members of a collective by highlighting a sense of shared experience, focus on alignment between worker and programme goals, and emphasise the actions that lead to good performance. The Social Identity Approach was selected as the theory most likely to lead to the development of effective, scalable and sustainable interventions by addressing the identified gap in the literature of the influence of CHW working context. The formative research indicated that CHWs value feedback and feeling connected to the health system and their community, are motivated by status and community standing, and want to be provided with the necessary tools to perform. Two interventions based on these results were developed: a participatory, local community approach and an information communication technology (ICT) approach.ConclusionsDrawing on contextual data and theory that is sensitive to context can potentially lead to the development of appropriate and effective interventions when aiming to improve the motivation, retention and performance of CHWs in Uganda and Mozambique and other comparable settings. Evaluation of the developed interventions is crucial to assess this potential.

Background Effective referral systems from the community to the health care facility are essential to save lives and ensure quality and a continuum of care. The effectiveness of referral systems in Mozambique depends on multiple factors that involve three main stakeholders: clients/community members; community health workers (CHWs); and facility-based health care workers. Each stakeholder is dependent on the other and could form either a barrier or a facilitator of referral within the complex health system of Mozambique. Methods This qualitative study, aiming to explore barriers and enablers of referral within the lens of complex adaptive health systems, employed 22 in-depth interviews with CHWs, their supervisors and community leaders and 8 focus group discussion with 63 community members. Interviews were recorded, transcribed and read for identification of themes and sub-themes related to barriers and enablers of client referrals. Data analysis was supported by the use of NVivo (v10). Results were summarized in narratives, reviewed, discussed and adjusted. Results All stakeholders acknowledged the centrality of the referral system in a continuum of quality care. CHWs and community members identified similar enablers and barriers to uptake of referral. A major common facilitator was the existence of referral slips to expedite treatment upon reaching the health facility. A common barrier was the failure for referred clients to receive preferential treatment at the facility, despite the presence of a referral slip. Long distances and opportunity and transport costs were presented as barriers to accessibility and affordability of referral services at the health facility level. Supervisors identified barriers related to use of referral data, rather than uptake of referral. Supervisors and CHWs perceived the lack of feedback as a barrier to a functional referral system. Conclusions The barriers and enablers of referral systems shape both healthcare system functionality and community perceptions of care. Addressing common barriers to and strengthening the efficiency of referral systems have the potential to improve health at community level. Improved communication and feedback between involved stakeholders – especially strengthening the intermediate role of CHWs – and active community engagement will be key to stimulate better use of referral services and healthcare facilities. Electronic supplementary material The online version of this article (10.1186/s12913-019-4076-3) contains supplementary material, which is available to authorized users.

BackgroundCommunity health workers are reemerging as an essential component of health systems in low-income countries. However, there are concerns that unless they are adequately supported, their motivation and performance will be suboptimal. mHealth presents an opportunity to improve support for community health workers; however, most interventions to date have been designed through a top-down approach, rarely involve the end user, and have not focused on motivation.ObjectiveTo use formative research to explore the views of community health workers in Uganda and Mozambique on the potential role of mHealth in their work delivering integrated community case management of children.MethodsWe conducted 24 in-depth interviews and 5 focus group discussions with community health workers in Uganda and Mozambique. Data were collected on: current phone use, preferred phone and charger characteristics, and perceptions of a range of potential mHealth interventions. Interviews were conducted in the local language, were audio recorded and converted into expanded notes. Interviews were coded for key thematic areas using both deductive and inductive codes. Deductive codes included mHealth’s potential impact on motivation and performance.ResultsThe most salient roles of mHealth in improving performance and motivation were reducing the need for travel, improving efficiency and planning, receiving feedback and information, and improving communication with supervisors and other community health workers. This was mostly through improved voice and short message service (SMS) text communication. Specific components of mHealth interventions that participants felt could improve motivation included increasing their visibility and credibility through branding of phones; providing an SMS response to data submission; and sending SMS messages about the importance of their work and achievements, rather than just reminders or technical messages. Participants identified feasibility issues related to the language of SMS messages, network coverage, and the need for a balance between phone function and battery life. Phones with a dual SIM cards would ameliorate network problems but would reduce battery life. The provision of a solar charger was viewed as beneficial.ConclusionsConducting formative research with end users is likely to improve mHealth interventions by: (1) identifying interventions that are likely to have the greatest impact and be the most acceptable, (2) developing salient SMS messages, and (3) identifying feasibility issues. mHealth interventions also could have an important impact on health worker motivation, which should be considered by intervention developers and in evaluations, especially as small modifications could have a significant impact. Our study suggests that using phones to improve direct communication should be considered, even when planners aim to focus on the provision of a specific application.