in the world, within underserved populations with inadequate access to basic health services. An increasingly common approach to reaching these populations is community health worker programs. These programs aim to improve health outcomes among groups that have traditionally lacked access to adequate health care by recruiting community members to serve as connectors between healthcare consumers and providers.2 However, evidence indicates that there are mixed evidence of this approach in reducing child mortality.3 Weak incentives for community health workers to deliver timely and appropriate services are believed to limit the effectiveness of these programs.4 A potential solution may be financially sustainable delivery models where the health workers earn a margin on product sales and small performance-based incentives. This study in Uganda assesses the impact of such a non-profit entrepreneurial model of community health delivery.
Context of the Evaluation:Although infant and under-five deaths in Uganda have declined substantially is recent years, 69 out of 1,000 children in the country still die before age five.5 To reach an international target of reducing the under-five mortality rate by two thirds, Uganda will need to sustain a rapid rate of progress. 6
Living Goods, a U.S.-based non-governmental organization, created Living Goods Community Health Promoters (CHPs), with the aim of improving access to and adoption of simple, proven health interventions in rural and peri-urban areas in Uganda. The program is carried out in partnership with the Bangladesh-based non-profit BRAC. 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. Apart from providing health education and access to basic health products at low costs, this model aims to create sustainable livelihoods for the CHPs, who operate with financial incentives to meet household demand and receive small performance-based incentives for home visits and referrals.
Details of the Intervention:Researchers carried out a randomized evaluation to evaluate the impact of the Living Goods and BRAC Community Health Promoters (CHP) program on under-five mortality rate in rural Uganda. Researchers randomly assigned 214 villages across 10 districts to either the treatment group, which received the CHP program, or the comparison group, which did not receive the program.
Over a three-year period, CHPs conducted home visits in the 115 villages in the treatment group, educating households on essential health behaviors and offering preventive and curative health products for sale at 20-30 percent below prevailing retail prices. Prevention products included long-lasting insecticide treated mosquito nets, vitamins, and water purification tablets. Curative treatments included antibiotics, antimalarial drugs, oral rehydration salts, and zinc. Additionally, in order to incentivize the CHPs to provide maternal, newborn, and child health services, Living Goods pay CHPs US$0.20 for every home visit within 48 hours of delivery.
Ninety-nine villages did not receive the program and served as a comparison group. On average, around 38 households were surveyed per village at the end of 2013, for a total sample size of approximately 8,100 households.IPA conducted the final household survey in 2013, approximately three years of Community Health Promoters operating in the treatment villages. The primary study outcome is under-five child mortality rate over the period 2011-2013.
[Note: IPA only implemented final data collection, in 2013.]
Results and Policy Lessons:Results forthcoming.
[1] UNICEF. Millennium Development Goals: Child Mortality.
[2] Witmer, Anne, Sarena D. Seifer, Leonard Finocchio, Jodi Leslie, and Edward H. O'Neil. "Community health workers: integral members of the health care work force." American Journal of Public Health 85, no. 8_Pt_1 (1995): 1055-1058.
[3] Lewin, Simon, Susan Munabi-Babigumira, Claire Glenton, Karen Daniels, Xavier Bosch-Capblanch, Brian E. van Wyk, Jan Odgaard-Jensen et al. “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 (2010).
[4]“Community and Formal Health System Support for Enhanced Community Health Worker Performance: A U.S. Government Evidence Summit” USAID Final Report 2012.
[5] UNICEF. Information by Country: Uganda.
[6] Millennium Development Goals Report 2013: Drivers of MDG Progress in Uganda and the Implications for the Post-2015 Development Agenda.