The study aims at evaluating the impact of an innovative model of community health delivery implemented in Uganda by two NGOs, Living Goods and BRAC. Unlike most volunteer-based community health worker programs, the community health promoters (CHP) program implemented by the two NGOs harnesses the power of franchised direct selling to provide CHPs with incentives to increase access to low-cost, high-impact health products and basic newborn and child health services.
The CHP program is organized into geographically based branches, and managed by branch managers and supervised by the two NGOs. The CHPs are selected through a competitive process among female community members aged 18 to 45 who apply for the position. CHPs receive an initial 2-week training on health and business topics, before being deployed within their village. The CHPs tasks are to conduct home visits, educate households on essential health behaviors, provide basic medical advice, referring the more severe cases to the closest health center, and sell preventive and curative health products. The product line they have at disposal include prevention goods (e.g. insecticide treated bednets, water purification tablets, and vitamins), curative treatments (e.g. oral rehydration salts, zinc, and ACTs), as well as other health-related commodities (e.g. diapers, detergent, and hand soap) and durables with health benefits (e.g. improved cook stoves, solar lights, and water filters). The products are sold by the CHP generally below prevailing market prices. The retail price is indeed determined by country management with a target of keeping prices for preventive and curative products below prevailing local market prices. The CHPs, in turn, purchase these products directly from Living Goods or BRAC branches at even lower wholesale prices and therefore earn an income on each product sold. Thus, the CHPs operated as micro-entrepreneurs with financial incentives to meet household demand.
A first evaluation of the impact of the CHP program was conducted between 2011 and 2013. The evaluation, based on a cluster-randomized controlled trial, found that the CHP program was highly effective in reducing child mortality. This study, which also relies on a cluster-randomized controlled trial methodology, represents a follow-up evaluation, which takes advantage of the scaling up of the CHP program within Uganda. Its aim is to test whether the positive impact can be sustained as the project gets scaled-up. More specifically, the main question this study will answer is: can the reduction in under-5, infant and neonatal mortality observed in the first study be sustained when the program is running at scale?
The results from this evaluation will allow for better understanding the long term effect of this innovative program for community health delivery, once it operates at scale, and will moreover inform the Ugandan authorities about the added value of a different CHW cadre in which health workers receive financial incentives. The evidence can also be used to inform other programs and guide other international organizations, governments and stakeholders to design effective programs for improving child health in areas underserved by the official health system.