Scaling Up an Entrepreneurial Model of Community Health Delivery in Uganda
Millions of children die from preventable diseases every year, primarily in low-income countries. In rural Uganda, researchers are working with Innovations for Poverty Action to evaluate the impact on child mortality of an at-scale community health worker program based on a micro-franchise business model. An initial impact evaluation of this program in Uganda found a significant reduction in infant and child mortality, as well as improved health knowledge among clients and an increased number of household visits by health workers. Results from this evaluation of the scaled-up program are forthcoming.
Despite improvements in under-five mortality, an estimated 5.9 million children worldwide died in 2015.1 More than half of these deaths were caused by conditions that could have been prevented or treated with simple, affordable interventions. A majority of these deaths occur in low-income countries, and among populations with inadequate access to basic health care. An increasingly common approach to reach vulnerable populations is community health worker programs, which aim to improve health outcomes by recruiting members of the local community to connect healthcare consumers and providers.2
Community health worker (CHW) programs train local community members in basic health knowledge and diagnosis and treatment of illnesses, typically at the village level. CHWs are usually volunteers who provide a range of health activities in their village through home visits and community meetings, including health education, family planning, distribution of preventive care products (for example, insecticide-treated bed nets), and diagnoses and treatment of simple illnesses. CHWs also serve as the link between the community and the formal health system by providing referrals to health centers.
However, evidence indicates that CHW programs have had mixed success in reducing child mortality.3 Research shows that weak incentives for volunteer community health workers to deliver timely and appropriate services is an important factor limiting the effectiveness of these programs.4 A recent evaluation of a micro-franchise model, in which health workers earn small performance-based incentives and receive profits from sales of preventive care products, found that this system improved service delivery and health outcomes.5 In this follow-up study, researchers are assessing the impact of a scaled-up version of this entrepreneurial model of community health delivery in Uganda.
Context of the Evaluation
Although child mortality in Uganda has declined by nearly 70 percent since 2000, in 2015, 55 of every 1,000 children born alive in Uganda died before age five.6
In response to this challenge, Living Goods, an NGO based in the US, created a Community Health Promoters (CHP) program in partnership with BRAC Uganda and Uganda’s Ministry of Health. The CHP program is designed to improve access to and adoption of simple, proven health interventions among low-income households in Uganda. CHPs are women trained to operate micro-franchises, which sell a line of health products below market price, door-to-door, to households in their communities. In addition to providing health education and access to basic health products for low-income households, this model aims to create sustainable livelihoods for the CHPs, who can earn an income through profits from product sales and from small, performance-based incentives to encourage registering and monitoring the health of pregnant women and newborns.
A randomized evaluation of the CHP program from 2011-2013, implemented by Innovations for Poverty Action (IPA), found a 27 percent reduction in under-five child mortality, with similar effects for neonatal and infant mortality. This evaluation also found that the program improved health knowledge among community members, increased preventive health behavior and care-seeking, and provided suggestive evidence that antimalarial drug quality improved in areas where CHPs were operating. These encouraging results have motivated Living Goods and BRAC to significantly scale up their operations in East Africa.
Details of the Intervention
Researchers are now working with IPA to carry out a randomized evaluation to assess the impact of the scaled-up CHP program across 500 rural villages in 13 districts across Uganda. Researchers randomly assigned 250 villages to receive the CHP program, and 250 villages to a comparison group, which will not receive the program. The villages in this study did not have an existing CHP program, and were not included in the first evaluation.
Qualified CHPs are selected through a competitive application process in each treatment village, and trained for two weeks on health topics and in business skills. These CHPs will conduct home visits in treatment villages over the course of three years, educating households on essential health behaviors, providing basic medical advice and referrals for more serious diagnoses, and selling discounted preventive and curative health products. CHPs can purchase these products directly from Living Goods or BRAC branches at an even lower price, allowing them to earn a profit on each product sold. In order to incentivize the CHPs to provide maternal, newborn, and child health services, the program pays them an additional US$0.65 for every newborn home visit and registration that is completed.
The primary objective of the study is to estimate the impact of the CHP program on child mortality after three years. The researchers will also collect information on household health knowledge and behavior, child health status, community health promoter knowledge and behavior, and price and quality of drugs sold in the local markets.
Results and Policy Lessons
Project ongoing; results forthcoming.
1. WHO. 2016. “Children: reducing mortality.” Last modified September. Accessed October 7, 2016. http://www.who.int/mediacentre/factsheets/fs178/en/.
2. Witmer, Anne, Sarena D. Seifer, Leonard Finocchio, Jodi Leslie, and Edward H. O'Neil. 1995. "Community health workers: integral members of the health care work force." American Journal of Public Health 85: 1055-8.
3. Lewin, Simon, Susan Munabi-Babigumira, Claire Glenton, Karen Daniels, Xavier Bosch-Capblanch, Brian E. van Wyk, Jan Odgaard-Jensen, Godwin N. Aja, Merrick Zwarenstein, and Inger B. Scheel. 2010. “Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases.” Cochrane Database Syst Rev 3.
4. USAID. “Community and Formal Health System Support for Enhanced Community Health Worker Performance: A U.S. Government Evidence Summit.” Kaiser Family Foundation, 2012.
5. Björkman Nyqvist, Martina, Andrea Guariso, Jakob Svensson, and David Yanagizawa-Drott. “Effect of a micro entrepreneur-based community health delivery program on under-five mortality in Uganda: a cluster-randomized controlled trial.” CEPR Discussion Paper DP11515, September 2016.
6. UNICEF. “Levels and Trends in Child Mortality.” 2015, 26.