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Evaluation of Living Goods/BRAC entrepreneurial CHW model in Uganda - Phase II

Last registered on October 10, 2017
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Pre-Trial

Trial Information

General Information

Title
Evaluation of Living Goods/BRAC entrepreneurial CHW model in Uganda - Phase II
RCT ID
AEARCTR-0002392
Initial registration date
October 10, 2017

Initial registration date is when the trial was registered.

It corresponds to when the registration was submitted to the Registry to be reviewed for publication.

First published
October 10, 2017, 3:13 PM EDT

First published corresponds to when the trial was first made public on the Registry after being reviewed.

Locations

Country
Uganda
Region

Primary Investigator

Name
Martina Björkman Nyqvist
Affiliation
Stockholm School of Economics
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Other Primary Investigator(s)

PI Name
Andrea Guariso
PI Affiliation
Trinity Colleg Dublin
Contact Investigator
PI Name
Jakob Svensson
PI Affiliation
IIES, Stockholm University
Contact Investigator

Additional Trial Information

Status
On going
Start date
2016-01-25
End date
2019-12-31
Keywords
Health
Additional Keywords
Child Mortality, Public Health, Social Entrepreneurship; Community Health Worker
JEL code(s)
O12, I11, I12
Secondary IDs
Abstract
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.
External Link(s)
Short study description
Summary of the study that evaluated the original program

Registration Citation

Citation
Björkman Nyqvist, Martina, Andrea Guariso and Jakob Svensson. 2017. "Evaluation of Living Goods/BRAC entrepreneurial CHW model in Uganda - Phase II ." AEA RCT Registry. October 10. https://doi.org/10.1257/rct.2392-1.0
Former Citation
Björkman Nyqvist, Martina, Andrea Guariso and Jakob Svensson. 2017. "Evaluation of Living Goods/BRAC entrepreneurial CHW model in Uganda - Phase II ." AEA RCT Registry. October 10. https://www.socialscienceregistry.org/trials/2392/history/22208
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Experimental Details

Interventions

Intervention(s)
The intervention evaluated within this trial is a novel “social entrepreneurship” approach - the Living Goods Model - to community health delivery. It is a community health worker program in Uganda, where community health promoters (CHP) operate as micro-entrepreneurs earning an income on the sale of preventive and curative products to keep them motivated and active in the community.

The CHP program is organized into geographically based branches, and managed by branch managers and supervised by the two NGOs Living Goods and BRAC. Each Community Health Promoter is assigned to a specific cluster, which in most cases corresponds to a village. 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 received 2 weeks of health and business training, covering preventing, diagnosing and treating childhood illness, recognizing danger signs for referral, healthy pregnancy and newborn care, and nutrition. At the end of the training, a skills test is administered to determine who would become an active CHP. Selected CHPs also attended a one-day training each month to review and refresh key health and business topics.

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.
Intervention (Hidden)
Intervention Start Date
2016-05-09
Intervention End Date
2019-10-01

Primary Outcomes

Primary Outcomes (end points)
Child mortality (infant mortality, neonatal mortality, under-5 mortality).
Primary Outcomes (explanation)
Our primary outcome of interest to evaluate the impact of the program is child mortality. We will compute child mortality using information contained in the household survey. The survey records: 1) detailed birth information on all children under five living in the households at the time of the survey; 2) detailed birth and death information on all children that died under the age of five during the study period; 3) detailed birth and (if the child died) death information on all children that were under the age of 5 and were recorded as living in the study households at the time of the baseline. At endline, for each child, we will define the number of month of exposure to the risk of death during the trial period, defined as the difference between the birth date of the child, or the start date of the trial if the child was born before that date, and the date that the child turned five years if that occurred during the trial period, or the date of the endline household survey if the child was less than five years old at that time, or the date of the death of the child. Under-five mortality will then be calculated as number of under-five deaths over the trial period per 1000 child-years of exposure to the risk of dying under the age of five. We will also compute infant mortality as number of deaths during the trial period arising within the first year of life per 1000 infant-years of exposure, with infant-years of exposure calculated in a similar way as the child-years of exposure to the risk of death. Finally, we will compute neonatal mortality as the number of deaths during the trial period within the first month of life per 1000 births.

Secondary Outcomes

Secondary Outcomes (end points)
1) HH interactions with Living Goods/BRAC CHP

2) Health Outcomes (Height-for-age and Weight-for-height for children under-5 living in the household (expressed in z-scores); Malaria, diarrhea and pneumonia prevalence among children under-5; Share of miscarriages and stillbirths; Number and frequency of pregnancies and births)

3) Health Knowledge (causes and treatment of malaria and diarrhea; breastfeeding practices; familiarity with food with added vitamins or nutrients)

4) Household Health Behavior (standard prevention and treatment practices for diarrhea, malaria, and acute respiratory infections; food consumption habits ; Ante-natal and post-natal care practices, including breast-feeding practices)

5) Health services (Whether household received follow-up visits by health staff following health-related problems with children under-5, or delivery; Whether household received referrals to a health facility due to health-related problems with children under-5, or pregnancy; Whether pregnant women in the hoodhoods received counselling and health recommendations)

6) Community Health Workers knowledge and activity (Level of satisfaction and confidence; self-reported activity ; knowledge concerning malaria and diarrhea; Revenues)

7) Drugs quality (Average quality of the ACT and amoxicillin drugs sold in the village stores (village level variable); Number of drug stores that opened (closed down) during the study period (village level variable))
Secondary Outcomes (explanation)

Experimental Design

Experimental Design
The study is a stratified cluster randomized controlled trial embedded in the scale up of the CHP program. 500 trial clusters, organized into 15 zones which span 13 districts in four regions of Uganda, will participate in the trial. Each trial cluster is one village (LC1). Each zone contains villages that are assigned to one Living Goods or BRAC branch. Within each of the 15 zones, the villages are randomly divided into an intervention group and a control group (randomized block design), using balanced randomization. None of the villages included in the study has been exposed to the CHP program before. CHPs will be assigned to each village in the treatment group, while no CHP will be assigned to villages in the control group.
Experimental Design Details
Randomization Method
Random number generator on a computer.
Randomization Unit
The unit of randomization in the study is a village. Within each of the 15 study zones, the villages are randomly divided into an intervention group and a control group (randomized block design), using balanced randomization.
Was the treatment clustered?
Yes

Experiment Characteristics

Sample size: planned number of clusters
500 villages
Sample size: planned number of observations
12,500 households
Sample size (or number of clusters) by treatment arms
The sample is equally divided to 250 treatment and 250 control villages. From each of these villages, 25 households will participate in the survey (a total of 6,250 households in the treatment and 6,250 in the control villages).
Minimum detectable effect size for main outcomes (accounting for sample design and clustering)
The sample size was designed to detect a 20% reduction in under-5 mortality, expressed as number of under-5 deaths per 1000 child years of exposure to the risk of death under the age of 5. Data from the control group in the 2014 impact evaluation of the Living Goods / BRAC CHP program was used to estimate the required sample size. Using 80% power to detect a 20% reduction in under-5 mortality at the 0.05 significant level, the sample size was set at 250 clusters per arm, for a total sample of 500 clusters, and 25 households per cluster (12,500 household respondents in total). This design and sample size also has 80% power to detect a 22.3% reduction in infant mortality and a 25.7 % reduction in neonatal mortality at the 0.05 significant level.
Supporting Documents and Materials
IRB

Institutional Review Boards (IRBs)

IRB Name
Uganda National Council for Science and Technology
IRB Approval Date
2015-10-15
IRB Approval Number
SS 3938
IRB Name
Mildmay Uganda Research Ethics Committee
IRB Approval Date
2015-09-21
IRB Approval Number
0109-2015
IRB Name
IPA Institutional Review Board
IRB Approval Date
2015-10-15
IRB Approval Number
13774
Analysis Plan

Analysis Plan Documents

Pre-analysis plan

MD5: 4aac95ae42c9f36f319b08ad6d192c19

SHA1: 16a200a798d4075db0bbe13deea88592dba404a0

Uploaded At: October 09, 2017

Post-Trial

Post Trial Information

Study Withdrawal

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Intervention

Is the intervention completed?
No
Data Collection Complete
Data Publication

Data Publication

Is public data available?
No

Program Files

Program Files
Reports, Papers & Other Materials

Relevant Paper(s)

Reports & Other Materials