Uganda: CHW Performance Affected by Tech Challenges

OUR LEARNING SITE AT SCALE: Performance for Q3 is generally below H1 results, due to persistent tech issues and strict lockdowns, but still largely remains at or above target despite these challenges.  Free medicines, CHW incentives, and strong remote supervision by a dedicated team continue to drive performance. Each CHW provided an average of 26 treatments or positive diagnoses to U5 children against the target of 18, and most pregnant women registered by a CHW delivered at a health facility (91% versus the target of 85%).

However, on-time PNC visits continue to struggle. To bolster this indicator, we are conducting refresher trainings for CHWs on how to calculate expected delivery dates, emphasizing following up on all pregnancies, and increasing the number of related follow-up visits—given the strong association between these and on-time PNC rates.

As noted, continued tech glitches such as logouts and system crashes affected CHW performance this past quarter. Medic’s Community Health Toolkit (CHT) platform, which the Smart Health app is based upon, is not designed to handle our vast amount of data—an issue that has only escalated as we have scaled. This has created inputting, syncing and data flow challenges, which has compromised our ability to receive and review data on time.

One of our top priorities moving into 2022 is to ensure that the Smart Health app is stable and scalable. We are hopeful that upgrading to a new Medic version of the core CHT platform this year and working closely with them to advance it will significantly improve the situation—both for ourselves and for anyone wanting a solution that needs to operate at significant scale.

OYAM DISTRICT IMPLEMENTATION SUPPORT: We support nearly 200 CHWs in Oyam district, our first test of government-led and co-financed implementation support site in Uganda. Performance of iCCM indicators fell in Q3, affected mainly by commodity shortages at health facilities, leading to low stocks of essential medicines at the CHW level. Highlights included supervision, facility referrals completed, and facility deliveries—all above target—indicating strengthened linkages with the primary health system.

Our work in Oyam is an experiment intended as an advocacy tool to influence district and national government on the importance of community health driven by DESC components. We continue to support the district in managing CHW performance and engaging partners, including ensuring that CHWs are compensated and sufficiently stocked. Dashboard usage is strong, with government supervisors consistently accessing them to monitor performance. We are also supporting the MoH to establish the Oyam Community Health Exemplar Technical Advisory Committee, a multisectoral committee that will be essential for the project’s success. We’re also seeing continuous improvement on the compensation front although the overall amount remains low; 64% of Oyam CHWs were compensated in Q3, almost double the 35% rate we saw in Q1.

BRAC PERFORMANCE: Our partner BRAC had high rates of active CHWs and record levels of sick child assessments and treatments in Q3, continuing a strong upward trend from the end of 2020. Technology has been a key focus and performance driver, with widespread phone replacements last year and an mHealth upgrade with Medic leading to greatly improved platform functionality. This, and having fewer workflows and historical data than Living Goods, has helped them avoid the bulk of the tech glitches affecting our learning sites.

Another performance driver has been consistent in-person supervision. This is something Living Goods continues to review and consider depending on staff and CHW vaccination rates, but safety remains our top priority. BRAC’s peer supervision experiment is further driving results; based on Living Goods’ success in this realm, it involves a high-performing CHW overseeing five lower-performing CHWs. An evaluation of the 413 CHWs involved in the program found that peers enabled an increase in household visits by an average of 33% and U5 assessments by an average of 56%.

Building on Living Goods’ learnings, CHWs also remain highly engaged in family planning activities since they started them in Q2.  More than 20,000 family planning-related visits were conducted in Q3, mostly done in September after the COVID lockdown was lifted.

THE CHANGING COVID-19 CONTEXT: Uganda’s national COVID infection rate is down, meaning that more CHWs can proactively support in-person health activities and encourage more households to get vaccinated. Personal protective equipment (PPE) has been a key motivator in their ability and desire to do so. Supervisors are also working to educate and build confidence among CHWs to reduce COVID-19 fears and increase their activity and vaccination rates. This comes as vaccines are increasingly available and the country targets to vaccinate about 12 million people by the end of the year. By first week of November, about 6% of Uganda’s population was at least partially vaccinated, while about a third (2,970) of the CHWs Living Goods and BRAC supports are.

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