2 0 1 5 E A S T A F R I C A E V I D E N C E S U M M I T J U LY 8 - 9 , 2 0 1 5 | N A I R O B I , K E N Y A

WORKING WITH VILLAGE HEALTH TEAMS (VHTS) TO INCREASE ORAL REHYDRATION SALT (ORS) USE IN UGANDA: A RANDOMIZED CONTROL TRIAL ZACHARY WAGNER, JOHN BOSCO ASIIMWE, DAVID LEVINE & WILLIAM DOW

Motivation

• Diarrheal diseases are the second leading cause of child mortality under-5 (Liu et al. 2012)

• In Uganda, under 5 child mortality is 90 per 1000. Diarrhea accounts for 13% total children’s deaths

• Diarrhea is preventable. It is also cheaply treatable through the use of oral rehydration salts (ORS) (Spandorfer et al. 2005, Munos, Walker, and Black 2010)

• In Eastern Uganda, the location of the proposed study, under 40% of diarrheal cases are treated with ORS (UDHS 2011).

Background

• Working with VHTs may increase use ORS, which is key in reducing under-5 mortality in Uganda

• In 2001, government of Uganda established VHTs in an effort to increase ORS use and other health interventions in rural areas

• VHTs were brought on board due to: - Severe shortage of trained health

worker (Dambisya and Matinhur, 2012)- Health worker to population ratio in Uganda is low 1:1298 compared to recommended World

Health Organization (WHO) of 1:439 (MoFPE, 2013).

Literature Review

• Basinga, et al., 2010 – research on incentives• WHO,2007 – essential health services cannot be

provided by people working on a voluntary basis• Dambisya et al., 2012 – on diarrhoea case

management in low income countries • Wagner et al., 2014 – inconvenience for

mothers/caregivers to visit the VHTs

Location of Study

Area of Study

Intervention

• VHTs are community-based and community-run health services in Uganda

• They are not trained medical health worker• They work on voluntary basis• They are ‘self’ selected and informally confirmed by

the village leader (local council chairperson)• They are expected to be trained in 5 days (training

manual by MoH available) on a range of health care service including disease prevention & treatment

Structure of Uganda’s Health System

Village expected to have 2-5 VHTs. 100 HH

Parish - HCII

Sub-county - HCIII

District – HCIV or Hospital

Reg/National – Referral Hospital

VHT Tasks/Roles • Community mobilization and empowerment: home

visits, health records, community meetings, distribution of medical supplies.

• Health surveillance and simple treatments: disease surveillance (disease outbreaks), illness treatment, hospital referrals and monitoring of child growth

• Environmental health: water, sanitation & hygiene• Behaviour change: Promotion of healthy practices:

handwashing, use treated mosquito nets, immunization

Challenges

• High levels of attrition seen among VHT workers (MoH, 2013).

- Villages with presence of VHTs dropped from 78% (FY2011/12) to 55% FY2012/13

• Attrition due to being overworked and receiving no compensation (voluntary basis)

• Attrition is also due to lack of medical supplies (ORS) at the health facility

Goal of Study

This study aims to address barriers related to low ORS use, by:

- Training VHTs on proper ORS use- Educating mothers on proper ORS use- Work with VHTs to directly distribute ORS to households- Provide financial incentives to VHTs to

improve performance

Design

• Clustered randomized controlled trial - Select a region with high incidence of

diarrhoeal: Eastern region (diarrhoeal incidence 33% vs national rate is 23% (UBOS, 2012))

- Select one district within the Eastern region- Randomly select 4 sub-counties from selected district - Randomly select 68 eligible villages; 34

villages/clusters allocated to treatment 34 to control• Sample size 1,000 households; 14 households per

village

Treatment

• Treatment: Training + delivery of ORS+ ZINC to households with children under 5 (with financial compensation to VHTs for delivery)

• Control: Training of VHTs

Research Questions

• Does offering financial incentives to VHTs to deliver ORS at home increase ORS use?

• Does home delivery of ORS by VHTs reduce the time when diarrhea treatment is initiated, once a diarrhea episode starts?

Empirical Specification

•𝑌𝑖t health outcome for each selected HH i.e ORS use, time to ORS initiation, and whether ORS is stocked•Treat is a dummy for the treated=1; 0 otherwise •Post is a dummy for the intervention period i.e endline=1 and 0 otherwise•X is a vector of households characteristics (assets proxy for wealth, HH size, education level of the mother or caretaker and distance to HC) •v captures village fixed-effects •u is the individual’s error term

Yitv=δ0+Treat.Postitvδ3 +Xitvβ+Vv+uitv

Next Steps

• Conduct Formative Research- Work with the ministry of health, local health

officials, village leaders, VHTs, NGOs and mothers/caregivers to craft the intervention and assessacceptance and appropriateness of incentive

• Ensure political feasibility and buy-in of study• List villages • Average pay per VHT will be 15US$ per month (figure

based on village level wages); discuss possibility to offer different levels of incentives?