By Kingsley Chikaphupha and Maryse Kok
Supervision is one of the most challenging elements of close-to-community programmes yet it is considered one of the most important elements. In Malawi a lack of recognition is a demotivating factor for health surveillance assistants (HSAs) which has a knock on effect on their performance. Our intervention trialed a number of new ways of supporting HSAs – and these were met with a variety of outcomes. In this blog, we explore some of the unanticipated negative consequences of introducing awards for well performing community health workers and suggest ways that they can be overcome.
During our research we found that, if they were performed at all, performance assessments of HSAs in Malawi focused on checking registers or attendance and did not include evaluation of the quality of services that were delivered. The community was not asked to provide feedback, and limited feedback was provided to HSAs on how they were performing according to programme indicators and targets. To overcome this, we planned an intervention to strengthen supervisory systems.
Firstly, a training of 60 supervisors was conducted in Mchinji and Salima districts. The monthly group and peer supervision meetings that were introduced at the “block” level permitted supervisors and supervisees the opportunity to work as a team to meet common goals and objectives. Along this supervision intervention, we started a performance appraisal system for HSAs. The intervention introduced rewards to recognize best performance of HSAs. We learnt that the supervision training itself was motivating. A manager reported:
“Before the coming of REACHOUT, there was this other HSA who was so rude and uncooperative despite the fact that he was very good at his job. But today I thank REACH Trust for coming with the training of supervisors. When this project came we selected this troublesome HSA to undergo the training and today this HSA has completely transformed, his attitude is changed as well as his working ethics. He is the best block leader (supervisor) surpassing those who have been supervisors over the years and we actually recommend others to go and learn from him”.
HSAs were supervised and appraised over the period of a year, by their supervisors in cooperation with Reach Trust. Criteria that were used related to availability of work plans and the content of their reports (with 70% of activities to be successfully implemented), number of household visits, timeliness of reporting, meeting attendance, filing of data and availability of meeting minutes.
Based on this assessment we planned awards to recognize good performance. Rewards were organized around three categories of performance: best performing health facility, best performing block, and best performing HSA. The best performing facility got a trophy while wining blocks and individuals got rain coats and gumboots; safety boots and backpacks; and bicycles.
Smiling and sad faces could be seen during and after the awarding ceremonies. In Salima, some block members and HSAs whose colleagues won awards, agreed with the outcome and danced and congratulated their colleagues, while some were bitter and frowned. Other disgruntled individuals were angry that they had not been able to get awards. Some shouted they will no longer participate in the project because they did not win, they said they expected everyone to be rewarded. They felt this in spite of clear explanation on objectives, criteria, and the process of assessment which had been communicated at the beginning of the project by district health officials involved in the project as well as during the award ceremony itself. For the winners in Salima, it was time for celebration and they pledged to work even harder as they were motivated even more by the recognition they got from the project.
As a result of the awards it is likely that the winners will be highly motivated to work. However, it is also possible, going by the outbursts of HSAs who were not awarded in Salima, that HSAs’ disgruntlement may put them off the project. On the other hand, the attitude displayed by the HSAs in Mchinji gives us encouragement that the awards achieved their purpose i.e. to motivate all HSAs to work as hard and be dedicated, so they could emerge the winners next time.
The intervention was a good step in the direction of performance management, but improvements are needed with respect to assessment of performance of HSAs during household visits (actual observations) and possibly developing mechanisms to include the views of community members on HSAs’ performance. In this way, the system might be viewed as fairer, and decisions on who is awarded might be more accepted. Bottom line is these approaches are producing the fruits and they are worthwhile to implement. But it is important to acknowledge that despite good intentions the appraisal system and awarding of best performers had unintended consequences. In the future we hope that performance appraisal will be carried out taking into consideration suggested inclusions herein and that the intervention will be adjusted where needed. At the same time, we should realize that in some cases HSAs could stay demotivated, because human beings by nature have dissenting views to almost anything and everything.
This project is funded by the European Union.