Ugandan CHWs Maintaining Essential Services Despite Tech Challenges

CHWS ARE DOING A REMARKABLE JOB MAINTAINING ESSENTIAL HEALTH SERVICES DURING COVID-19. Under-five assessments (U5) per CHW reached 39.5 in Q3, our best performance on record and above the target of 32. We plan to transition from no to low-touch protocols in November, with CHWs resuming rapid malaria testing (mRDTs) rather than making presumptive diagnoses. U5 positive diagnoses and treatments per CHW were more than double the target of 16, increasing 27% from Q2 to 39.7 in Q3.   

Due to some challenges with our adjusted no-touch workflows that briefly prevented registering new mothers, pregnancies per CHW declined from 1.7 in Q2 to 1.5 in Q3. We returned to normal levels in September and are working to catch up with any pregnancies not properly registered during the quarter. On-time postnatal care (PNC) rates similarly had a slight decline due to technical glitches with the follow-up workflow.  

An area of standout performance is the number of 3-month active CHWs, which increased from 4,321 in Q2 to 4,400 in Q3. CHW motivation is very high, with 12-month attrition down from 16.6% in September 2019 to 8.6% in September 2020.  The drivers are strong supervision, CHWs feeling empowered and equipped to make a difference at this time, the new incentives structure, free medicines, and efficiency in phone replacement. Supervision also experienced a positive trajectory in Q3, with supervisors being intentional about supervising more CHWs using the new phone-based remote supervision approach.  

We are encouraged that our performance in family planning (FP) and immunization have been relatively steady in this new context. Although FP visits per CHW declined from 21.3 in Q2 to 16.9 in Q3, they are still above the target of 12. We expect to maintain this lower level going forward, as we are encouraging CHWs to improve client profiling by only targeting women eligible for FP, and to focus on quality visits that translate to method uptake.  Once we transition to low-touch protocols and can resume proactive household visits to new prospects, we hope to increase referrals and the number of first-time FP users. In Q4, we will continue to test the Sayana Press self-injection pilot.  

The percent of defaulters completing necessary immunizations remained above the target of 60% at 71%, with full immunization for children aged 9-23 months improving steadily to 73% in Q3. Given a worrisome decline in immunizations since the emergence of COVID, CHWs are playing a critical role ensuring that defaulters are identified, followed up with and linked to immunization services. 

We were able to achieve these results while keeping CHWs safe. Although there were 15 suspected cases of COVID-19 among CHWs in Q3, none were confirmed positive. Meanwhile, CHWs reported and referred 24,727 suspected community cases in Q3—only 21 of which were actually positive.  

Several technical challenges that have now been resolved affected our Q3 results. In addition to the workflow issues described above, and a related issue with task reminders, two-thirds of CHWs were suddenly logged out of the Smart Health app in July after our telecom provider abruptly changed our service agreement, which took time to rectify. We attribute these missteps to the heightened pressure to deliver updated digital tools under tight timelines during COVID-19, but they have reinforced the importance of strong testing protocols. To calculate Q3 KPIs, we have used data from the third of CHWs not affected by these issues as the best proxy for July and August performance. 

BRAC SAW IMPROVED CHW ACTIVITY AND HOUSEHOLD VISIT RATES IN Q3, with per CHW pregnancy registrations rising from 1.8 in Q2 to 2.4 in Q3. Both assessments and positive diagnoses and treatments per CHW increased, but still remain below target. These are expected to improve with stronger supervision and tech support, and the restocking of free medicines in early Q4. A total of 473 replacement CHWs were added in September via small group trainings, in adherence with COVID-19 protocols, and 26 Program Assistants were deployed in early July. A big focus of the quarter was around upgrading the Smart Health app, which forced CHWs to rely on paper-based reporting during August. BRAC plans to complete the upgrade by the end of the year and is equipping 90% of CHWs with replacement phones by November, which is expected to significantly resolve outstanding phone functionality issues and further improve CHW performance.  

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