Promoting Community Health in UgandaPDF version
The medical know-how needed to prevent and treat deadly afflictions such as malaria, diarrhea and malnutrition have been available for many years, but billions of dollars and a half-century of effort have failed to prevent 10 million children from dying of preventable diseases annually. This fact suggests that medical solutions are not the core of the problem, but that the lack of efficient, scalable, sustainable means of delivering them may be hindering preventive healthcare. Healthcare systems in developing countries suffer from numerous structural and functional problems, but there is little systematic evidence on how easy it is to impact the quality of healthcare delivery in developing countries, or how these improvements will impact the health of the population.
In Uganda, 31 percent of the population lives in poverty1 while only 49 percent of households have access to formal healthcare facilities.2 Access to formal healthcare is severely limited by poor infrastructure, particularly in rural areas where the majority of the population lives. A 1995 assessment of the burden of disease in Uganda indicated that 75 percent of life years lost to premature death were due to ten preventable diseases; among them, perinatal and maternal conditions (20 percent), malaria (15.4 percent) and diarrhea (8.4 percent).3
Two NGOs, Living Goods (LG) and Bangladesh Rural Advancement Committee (BRAC) are currently piloting an innovative model for solving part of the healthcare service delivery problem in Uganda. The project aims to improve access to and adoption of simple, proven health interventions in rural and peri-urban areas, while at the same time creating sustainable livelihoods for community-based health workers.
The model creates a network of door-to-door mobile Community Health Promoters (CHPs) who provide basic health education and make a modest income by selling a diverse array of basic health goods. This includes essential items emphasizing prevention like bed nets, condoms and water treatments. LG goes beyond the typical product mix offered to community health workers, by also providing its agents a broad assortment of consumer items that increase sales and thereby bolster their own financial sustainability so they remain effective in the long-run. Most health products are sold considerably below market prices, and in some cases provided for free where reliable subsidies are available. By establishing an efficient, secure supply chain LG aims to become a distributor of choice for free goods from the public sector. A CHP will be randomly assigned to half of the participating clusters of households.
CHPs receive three intensive weeks of health training plus monthly refreshers and regular coaching. LG provides CHPs a free kit including uniform, backpack, locking chest, market signs and visual flip charts for conducting village health forums. LG and BRAC are setting detailed health behavior change targets related to the basic diseases noted earlier, working with the endorsement of the Ministry of Health. They aim to: (i) reduce mortality and morbidity rates by at least 25 percent, especially for children under 5, and (ii) create a fully sustainable program whose CHPs earn US$200-500 per year. These outcomes will be the main focus in the impact evaluation.
The project will also attempt to assess how the introduction of a new actor affects both public primary healthcare delivery and the unregulated market of private outlets (where high markups and sale of counterfeit products are common). To the extent possible, the evaluation will also examine how improvement in health (if any) impacts other socioeconomic outcomes.
Results forthcoming.
1 UK Department for International Development, “Annual Report 2009 – Uganda,” http://www.dfid.gov.uk/Documents/publications/PSA/E_Uganda.pdf.
2 World Health Organization, “Health Systems: Uganda.”
3 World Health Organization, “Burden of Disease: Uganda.”
