Ugandan CHWs Maintain Strong Momentum, Despite COVID

Living Goods supported CHW Sarah Nakaggwa sensitises a client about the various modern family planning options she offers. Due to the COVID pandemic, CHWs and clients (above 6 years) have to wear PPE and keep at a distance.

CHWs continued their critical role ensuring continuity of care during the pandemic. Despite disruptions related to Uganda’s elections, they continued their strong performance in Q1 thanks to ongoing strong client demand, free medicines, and program adjustments such as our revised compensation structure, remote supervision and adjusted digital health workflows.

CHWs surpassed most indicator targets in Q1. Treatments or referrals for children under age five (U5) were more than double the target, and CHWs are increasingly targeting children under age one (U1)—those at greatest risk of U5 mortality. The rate of on-time postnatal (PNC) care visits was a below-target outlier of otherwise above-target numbers for Q1—at 68% against the target of 75%—but this improved by March, with field teams stepping up their focus on ensuring CHWs have women’s expected delivery dates in hand to encourage timely follow-ups.

We continue to find that CHWs trained in family planning (FP) and immunization (IZ) services visit far more households than their peers. About 69% of children who CHWs identified as under-immunized were confirmed to have completed their necessary immunizations in Q1. Vaccine stock-outs and transport challenges continue to be the primary impediments.

Demonstrating how dramatically sufficiently trained, supervised, and motivated CHWs can increase FP uptake, 47% of first-time users we support took up a method in Q1, compared to the national contraceptive prevalence rate of 41.8%. To increase FP uptake and put more power in the hands of women, we have been conducting a Sayana Press self-injection experiment. CHWs have already trained more than 300 women to inject themselves with the contraceptive, although uptake is low due to client fear of self-injection. We are optimistic that this will improve over time with education and behavior change efforts. When more data is available in Q2, we will decide whether to scale this approach.

BRAC continued its strong upward performance trend in Q1, with CHWs registering record results and surpassing most of their targets. The upswing was triggered by a mHealth upgrade completed last year and replacing all CHWs’ phones between October and January, which made it easier to capture health activities. Mentorship of supervisors on targeted coaching and additional IT training for CHWs also helped drive the improvement.

With our support, BRAC is gearing up to launch FP activities—including Sayana Press—in Q2, starting with more than 1,000 CHWs in three districts. The rollout was initially scheduled for 2020, but delayed due to COVID. BRAC is also drawing on Living Goods’ learnings as they work to launch the Smart Health Supervision App, expand remote supervision, and scale up a peer supervision experiment—in which select high-performing CHWs oversee a group of their peers. They are also focused on boosting on-time PNC visits—one of the few areas below target—by improving early identification of pregnancies and the rate of routine follow-ups.

In our new co-financed experiment in Oyam district, where we’re exploring how to expand partnerships with the government that influence policy, nearly 200 CHWs who comprise the effort’s initial prototyping phase are now providing families with digitally-driven health services. CHW performance was below target in Q1, but had a positive trajectory throughout the quarter. Pregnancies registered, child assessments, and treatments or referrals at least doubled from January to March, though remain well below target. Some of our challenges in Oyam include an imbalance in coverage—with too many CHWs in place for appropriate household coverage—and a compensation structure that is not sustainable in its current format. We always anticipate a slow start operating in new environments, as CHWs need time to acclimate to new ways of working and Living Goods and our partners must make context-specific adjustments before scaling up the test.

“Living Goods has changed my life by teaching me how to use technology and smartphones. I now treat children or refer them to health facilities with the help of a phone. I also use the phone for follow-ups because it sends me reminders. This keeps me informed—which in turn benefits my community.”

Emmanuel, a CHW in Oyam, as he demonstrates a child assessment workflow.

At a refresher training for the first 200 cohort of VHTs participating in the Oyam TA exemplar, VHT Emmanuel Ocira demonstrates how he uses the SmartHealth app and how it has eased his work.

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