Universal Coverage Mode RCT

Community Health Workers participating in the study will be providing care through the Proactive Community Case Management intervention, described in detail elsewhere. Through this package of services, CHWs are required to conduct at least two hours of home visits per day, six days per week, to achieve a goal of at least two home visits per household per month. All CHWs receive monthly individual supervision via a 360 Supervision protocol, described in detail elsewhere, as well as group supervisions weekly (at the Yirimadio site) or twice-monthly (at the Tori site). At the Tori site, households served by each CHW were previously registered via a population census which is updated every year by an independent team of surveyors. Within the Yirimadio site, all households have been registered by the CHW herself to achieve a ratio of approximately 1000 patients per CHW.

CHWs at both sites and both arms of the study will also receive monthly performance feedback via a CHW Performance Dashboard, described elsewhere, which provides personalized feedback on the quantity, speed, and coverage of care. CHW supervisors will be able to see their supervisees' performance data and provide feedback via the monthly supervisions. CHWs at both sites will receive feedback for community care management indicators, but only Yirimadio's CHW supervisors will observe CHWs performance on proactive household visits.

All CHWs at both sites use a CHW App, a free and open source smartphone application developed by Medic Mobile with Muso. The CHW App is a job aid that supports task management, panel management, and clinical decision support functions, while providing a mechanism for data collection and submission. Previously, CHWs had to manage 14 different types of paper forms that their core workflow entails, and the data was entered by hand for each of these forms to carry out monitoring and evaluation tasks. Now, there is no need for photocopying, carrying and stocking all 14 forms, and data is automatically sent to a central database once the smartphones are synchronized. Also, for CHW tracking their patients and the tasks they performed meant a huge organizational challenge. The app was modeled to tackle this problem using a human centered design, allowing the CHWs to easily search for and access their patients registries and histories.

For the control arm, all households within the CHW's household list in the app will have the same appearance. There will be no visual differentiation between households on the list to indicate the frequency of home visits.

In the intervention arm, the CHW's household list will appear differently within the app in the following ways:

The CHW will be able to filter and order households by the date of the most recent home visit, to identify households that have been visited least frequently.

A color-coded visual icon will display the number of home visits in the past month for each household.Red color for 0 home visits for a household in the past month (default at the start of every month).Orange color for 1 home visit for a household in the past month.Blue color for 2 or more visits for a household in the past month.

A red exclamation mark will be displayed for every household that has not reached 2 visits in the past month (default at the start of every month).

Text displayed below each household showing the date of last visit will turn red if more than 30 days have passed since last visit. When more than 60 days have passed since the most recent visit, the text displayed below each household showing the date of last visit will be changed to "date of last visit is unknown" in red.

The family profile will also contain the date of last visit, and the visits they have received in that month.