Management support and mHealth solution implementation to improve the Government of Sierra Leone Community Health Workers (CHW) program 50 views1 applications

1. Context

Despite unprecedented efforts and resources the Government of Sierra Leone, donors, and development partners have invested into the health sector over the last decade, the deadly Ebola Virus Disease (EVD) outbreak in 2014 further exacerbated the already weak health sector that is characterized by inadequate health workforce, poor infrastructure, high out-of-pocket expenditure, low health-seeking behaviours, weak information system especially at community level, high rates of child and maternal mortality – some of the highest in the world, and high level of mistrust among the population on the country’s health system. Latest WHO estimates from 2015 indicates that 1 in 17 mothers in Sierra Leone has a lifetime risk of death associated to childbirth, and 1 in 9 children die before reaching five. These and many more significant health challenges make Community Health Workers (CHWs) critical to increasing access to healthcare across the country and improving health indicators.

The launch of the revised CHW policy in February 2017 and the training of 15,000 CHWs has shown the government’s substantial commitment to the CHW program. However, management of a workforce of 15,000 CHWs requires robust systems to address the substantial increases in reporting (especially paper-based) and need to maintain quality of care over great geographic and contextual differences. Specifically, there is a clear need for supervisors and managers throughout the health system to have visibility over CHW activities, ensure CHWs are well supervised and incentives payments are disbursed on time and accurately to maintain motivation. Hence the establishment of the National CHW Hub within the Directorate of Primary Health Care (DPHC) charged with the responsibility to coordinate/manage the CHW program.

Digitizing data collection and reporting processes by providing CHWs and supervisors with a mHealth solution can provide greater transparency to CHW activities and improve performance, unlike the paper-based processes in use. However, technology alone will not deliver impact, users throughout the system need to understand the data and use it to improve the quality and efficiency of healthcare provision. In addition, efforts must be made to improve and ascertain the quality, availability, and reliability of the data collected and communicated, thus enhancing improvement in performance management, quality assurance and accountability.

Yet, introducing new technology on such a large scale requires developing the capacity of the Ministry of Health and Sanitation (MoHS) to own and manage the system. The MoHS strategic capacity to govern the data, drive behaviour change and ensure alignment with other initiatives must be supported, as well as the operational capacity to repair and maintain thousands of phones and manage the broader platform. This systems support will be critical to ensuring that the investment into CHWs delivers meaningful and sustainable outcomes.

2. Objectives

The objective of the required technical assistance is to implement Phase one of mHealth solution in Kailahun and Koinadugu districts for management of the CHW Program. An established mHealth platform will enhance data collection, performance management, incentive payment, real time reporting, monitoring and supervision, hence decision making. Processed data from CHWs activities will be validated and communicated through MoHS information systems/pathway. A feedback mechanism to CHWs and communities will be established to further improve performance, motivation, and ownership.

If the initial phase is successful and demonstrates adequate efficiencies and improved health outcomes, the program will be rolled out nationally (under another contract). Hence, all activities in phase one should be designed to be easily scaled nationally at the same or lower cost per capita.

3. Deliverables and activities

3.1 Co-design and implement a mHealth solution to improve delivery of supportive supervision, performance management and disbursement of incentives

a) Co-design the mHealth solution for CHW program

The mHealth solution for CHW needs to be a web based system and user friendly. It should:

i) Improve the community health workers program by enabling the capture of relevant data to support CHWs to deliver timely, equitable and high-quality care to maximize impact. This includes registration of households with a focus on women of reproductive age, caregivers, and children under five; registration of pregnant women to include capture data on expected date of delivery, antenatal (ANC) visits by CHWs and visits at facilities, and identifying high risk factors; recording of pregnancy, postnatal (PNC) and young infant visits and their outcomes; nutrition measurement and immunisation tracking and family planning counselling; recording of data from sick child assessments and treatments for disease tracking; community-based disease surveillance; default tracking and other relevant data to support improved targeting of care.

ii) Help to improve consistency and quality of care delivered by CHWs by: standardizing workflows for accurate diagnosis and treatment for iCCM; nutrition screening and support, flagging severe/acute cases for referral; ensuring timely follow-up on referrals; identifying risk factors during pregnancy and encouraging appropriate care-seeking behaviours for ANC visits and in-facility deliveries; ensuring appropriate care for newborns within 48 hours after birth and for children under 1 and identifying risk factors for TB and HIV; sending SMS messages to improve treatment adherence, provide reminders for mothers on immunization, nutrition, and pregnancy and newborn care; and support CHWs to do care coordination and prioritisation of activities and cases.

iii) Enable Peer Supervisors and Peripheral Health Units (PHU) in-charges, to manage performance by providing them with: up-to-date data on individual CHW performance; and reminders to make regular and individually contextualized supportive supervision visits including helping them to manage the timing of visits based on the performance of individual CHWs.

iv) Provide timely and accurate data on results being achieved at the community level, for action at all levels from CHWs, to Peer supervisors, In-charges, district and national level health teams, with a focus on integrating data flows into national health information systems. The data that is collected will feed directly into DHIS2. Any solution will need to be open source and Open HIE compliant to meet MoHS standards and to interoperate and/or integrate with MoHS information systems.

v) Trigger and promote actions to be taken by CHW and help prioritise CHW action to maximise reach and impact. Increase equity in service provision.

vi) Be co-designed with key stakeholders and MoHS staff, as well as develop through a human centred design process, ensure maximum utility to both direct users of the devices and the data.

b) Implement mHealth solution (CHW app and supervisor tablet app) to support diagnostics, case management, performance tracking and supervision for community health workers

The full range of activities to set-up and administer phones and tablets to users and ensure usage of the technology to delivery impact.

i) Administer phones and tablets

Carry out initial requirements gathering on hardware needs, procurement, asset registration and distribution and management of devices for phase 1. Administer data bundles to CHWs and Peer Supervisors/Managers so that they can regularly access and analyse performance data in real time on their tablets. The implementer needs to build skills within the government in order to manage the large-scale deployment of mHealth equipment.

ii) Train CHWs, Peer Supervisors, facility and district level staff

Train CHWs on how to use every feature of the mHealth app for CHW household visits including support to CHWs who have never used a phone or smartphone. CHWs should also understand how the data is being used, and how to explain to clients the role of the phone. Train Peer Supervisors, Peripheral Health Unit (PHU) in-charges, and CHW focal persons to use tablet supervisor application and best practices in supportive supervision including how to analyse performance data, identify weaker CHWs to provide additional support to, and reward and recognize well-performing CHWs.

iii) Ongoing support to supervisors

Support to Peer Supervisors, and PHU staff to use the data from the supervisor app to guide planning and execution of supervision visits. Implementer should provide hands-on and regular support (e.g. once a week) initially to all supervisors to develop the capacity of supervisors. They should aim to gradually reduce intensity of support (e.g. once a month) to the Peer Supervisors and facility-based supervisors as their capacity increases. Implementers should continue to accompany supervisors until supervisors are consistently delivering on agreed performance metrics.

3.2 Assist Ministry of Health and Sanitation (MoHS) and specifically the CHW Hub to improve management and quality of the CHW program

c) Manage mHealth solution

Build the capacity of the MoHS and individual departments including CHW Hub to own and manage the mHealth platform.

i) Procurement, registration and management of assets

Support MoHS to ensure that sufficient systems are in place to procure, host, register and manage devices so that this can be done efficiently over time and not impede the deployment and usage of devices in the field. Build capacity of the CHW Hub to administer data bundles routinely to all Peer Supervisors, CHWs and relevant users, and to efficiently manage the program.

ii) Helpdesk, troubleshooting, Android support

Provide technical assistance to ensure that over time the MoHS has the capacity to manage the repair, maintenance and replacement of devices themselves.

iii) Trainers

Train government trainer of trainers (TOT) to support CHW, Peer Supervisor, PHU and DHMT training so that they can provide the ongoing training needed to roll-out the solution at scale and when individuals are replaced. The eHealth Hub in MoHS will be instrumental in this regard.

d) Integrate with broader MoHS systems and process improvement

Ensure platform is co-designed with the MoHS and key stakeholders and implemented in alignment with wider MoHS activities.

i) Quality control and quality assurance

Implement robust quality control on data being collected through the devices to ensure high level of data accuracy and data integrity. Systems must be scalable but also provide high degree of assurance that data is credible and mechanisms to flag and rectify possibly false or inaccurate data.

Provide technical assistance to implement broader quality assurance and quality improvement approach to the model, so that quality of supervision and performance of all levels of the community health system is maintained. Data should feed into continuous improvements to the implementation of the policy or to the guidelines and standards themselves.

ii) Using mHealth solution to support performance – based incentives

Enable timely disbursement of incentives payments based on verifiable CHW and Peer Supervisor activity. Support the design and verification of performance targets so that all CHWs and Peer Supervisors have agreed and appropriate monthly performance targets. Data input through the mHealth solution should indicate as to whether CHWs and Peer Supervisors have met their targets, and quality control mechanisms should ensure that this data is accurate. Failing CHWs and Peer Supervisors should be flagged early and provided with support and guidance. Individuals should be aware of their own performance from performance trackers on their devices. Deliver training and support to PHUs, Peer-Supervisors and CHWs to ensure individuals understand which indicators drive incentives payments, and the process for ensuring that CHWs who have missed performance targets for valid reasons are not unfairly penalised.

Technical assistance should be targeted at increasing the capacity of all levels to improve performance; using the data to more effectively manage incentives, rewards, recognition and supervision.

iii) Harmonization across MoHS and support to scale

Provide technical assistance to the CHW Hub and across the MoHS including DPPI and other departments so that mHealth solution is integrated into broader eHealth activities, and the necessary policies, guidelines and standards are in place to enable solutions to scale. Any development of new capacity to support the CHW program must not be a replication of existing processes or functions within the broader MoHS. Support should be provided to develop the capacity of existing systems or align processes where relevant. Support M&E departments and team to utilise the data and adapt and develop M&E processes and systems to optimize reporting and the feedback loops into program improvement. Build the capacity of the DPHC to identify improvements to the CHW program and enable roll-out of program developments efficiently and without substantial disruption to the service.

iv) Last mile supply- chain support

CHWs require reliable access to essential medicines if they are to treat diseases such as pneumonia, diarrhoea and malaria. Regular current stock-outs at the facility levels limit the ability of CHWs to treat in the community. Work closely with Directorate of Drugs and Medical Supplies (DDMS) to develop solutions to address the last-mile supply chain issues which limit CHWs access to essential medicines.

4. Duration for the Assignment

The assignment is expected to be started in the first half of 2018 and last for twelve months.

5. Reporting arrangements

The consulting firm needs to submit quarterly implementation progress reports to Chief Medical Officer of Ministry of Health and Sanitation with copies to Directorate of Primary Health Care, Directorate of Planning and Policy Implementation, and the Integrated Health Project Administrative Unit (IHPAU). Copies of quarterly reports should also be shared with DHMTs as part of a feedback mechanism. In addition, quarterly financial management reports should be submitted to IHPAU.

Duration and timescale

The task should be delivered within a period of one (1) month the assignment is expected to be started in the first half of 2018 and last for twelve months.

The attention of interested Consultants is drawn to paragraph 1.9 of the World Bank’s Guidelines: Selection and Employment of Consultants [under IBRD Loans and IDA Credits & Grants] by World Bank Borrowers of January, 2011. (“Consultant Guidelines”), setting forth the World Bank’s policy on conflict of interest.

Consultants may associate with other firms in the form of a joint venture or a sub-consultancy to enhance their qualifications.

A Consultant will be selected in accordance with Quality and Cost Based Selection Method as set out in the Consultant Guidelines set out in the World Bank procurement regulations for IPF Borrowers July 2016 revised November 2017.

Copy of the terms of reference can be obtained on the address below by sending an email request.