We study the scaling up of an incentivized Community Health Worker program aiming at improving primary healthcare provision and reducing child mortality in rural areas of Uganda. The community health promoters (CHP) program is implemented in Uganda by two Non-Governmental Organizations – Living Goods (LG) and BRAC. One of the key innovations of this program is that, unlike most volunteer-based community health worker programs, it provides a set of financial incentives for the health workers. More specifically, there are two different categories of financial incentives. First, CHPs make profits by selling a range of health-related products to community members while carrying out their standard activities as community health workers. Second, they receive additional performance-based remuneration based on a set of key health activities that they perform, which include sick child assessment, registration and support of pregnant women, and visits to newborns in the first week of life.
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 applied for the position in each village and who possessed basic writing and math skills. Eligible candidates receive 3 weeks of health and business training. At the end of the training, candidates need to pass a skills test in order to be equipped as an active CHP. The NGOs provide an initial set of products to all newly recruited CHPs, together with a uniform, a mobile phone, and a set of training materials and visual aids to use during household visits. CHPs also attend a one-day training each month to review and refresh key health and business topics.
The CHPs tasks mirror the standard Community Health Workers tasks (conduct home visits, educate households on essential health behaviors, provide basic medical advice, referring the more severe cases to the closest health center), but on top of that, as mentioned above, they also sell preventive and curative health products. The product line they have at disposal includes 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, hand soap, fortified food) and durables with health benefits (e.g. improved cook stoves, solar lights, and water filters). These products are sold by the CHP at a discount. The retail price is determined by the NGOs head office with a target of keeping prices for preventive and curative products about 20% lower than the prevailing local market prices. The CHPs in turn purchase these products directly from Living Goods or BRAC branches at wholesale prices between 30-50% below market prices and therefore earn an income on each product sold. Thus, the CHPs operated as micro-entrepreneurs with financial incentives to meet household demand. The broad product mix has three potential benefits: (i) driving up total sales and income for the CHPs; (ii) enabling the NGOs to cross-subsidize prices (dropping prices on essential health products and increasing the margins on other products); (iii) motivating CHPs to be out visiting households regularly by including high-velocity items (such as soap and fortified foods) in the product mix. The business training received by the CHPs stresses the importance of building up a customer-base by providing free services like health education, referrals, and newborn visits. As described above, the income deriving from the micro-entrepreneurial activity is then further increased through performance-based incentives, designed by the NGOs to further encourage key health activities such as household visiting, sick child assessment, registration and support of pregnant women, and visits to newborns in the first week of life. Since 2013, Living Goods and BRAC also equip the CHPs with smartphones that includes a rich mobile health application. The application helps guide the CHW through workflows, keep track of their stock, serve as a client management system, and prioritize certain activities based on timeliness (e.g. pregnancy follow-up) or household risk. Overall, this allows monitoring the CHPs’ activity, while collecting real-time health data from the field.
A first evaluation of the impact of the CHP program began in 2010 (Björkman Nyqvist et al, 2019). The evaluation was based on a cluster-randomized controlled trial that involved 214 villages in 10 districts across Uganda. The villages were stratified by geographical zones and 115 villages were randomly assigned to the treatment group, where the CHP program started operating in January 2011, while 99 villages were assigned to the control group. The evaluation was based on an endline survey collected at the end of 2013, which covered 7,018 households and 11,563 children under-5 that lived in the same village throughout the trial. The study found that over the three years the CHP program reduced under-5 mortality rate by 27% (adjusted rate ratio 0.73, 95% CI 0.58-0.93) in the treatment compared to the control arm. The effects were of similar order of magnitude for infant mortality (adjusted rate ratio 0.67, 95% CI 0.51-0.87) and neonatal mortality (adjusted rate ratio 0.73, 95% CI 0.55-0.98).
Following the first study, the program has been massively scaled up across Uganda. The study presented in this submission takes advantage of the scaling up of the program to investigate the following two key questions: 1) Can the reduction in child mortality observed in the “proof-of-concept” study be sustained when the program is scaled-up? 2) 2) What is the impact of scaling up an incentivized community health worker program on existing health service providers?
This new study involves the same main actors of the first one: program implementers, data collection agency , and funding agency. This helps ensuring that the design, the management, and the implementation of the research program remains the same as in the first study. There are, however, also few important differences: the new study will measure treatment effects over a longer time period , it relies on a much larger sample (500 villages and more than 12,500 households), it exploits a much richer set of data, including survey data from other providers in the community, and it relies on a panel of households identified at baseline, rather than on a cross-section.
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.