New community health programme linked to decreased child mortality in Uganda

An innovative “Avon-like” community health programme introduced in Ugandan villages has been linked to significant decreases in infant and child mortality.

The collaborative study, recently published in the American Economic Journal: Applied Economics,includes Dr Andrea Guariso from Trinity College Dublin and researchers from the Stockholm School of Economics, Stockholm University and University of Zurich.

Despite significant progress over the last few decades, the World Health Organisation (WHO) estimates that about one in thirteen children in sub-Saharan Africa still die before reaching their fifth birthday. The risk of death in the region is 15 times higher than in Europe.

This project, run by the US-based Living Goods in collaboration with BRAC Uganda, relies on a network of Community Health Promoters to go door-to-door to sell basic health goods, including anti-malaria drugs, soap, insecticide-treated bed nets, clean cook stoves, and fortified foods. The model is based on “Avon-like” networks of door-to-door mobile Community Health Promoters.

The health promoters – women recruited from within the communities they serve – are not medical professionals but are trained to detect danger signs in the home, to diagnose and treat childhood illnesses, and to refer any severe cases to clinics.

The researchers found that death rates dropped by 27% for children under five and 33% for infants through the programme. The study was conducted over three years.

The results point to a potentially low-cost and sustainable model that would help sub-Saharan African communities better protect their most vulnerable people.

A key innovation is that these workers are compensated. Other similar efforts have relied on volunteers to provide household services, but those have struggled to keep workers motivated. Living Goods workers, by contrast, operate as “micro-entrepreneurs.” Similar to the direct sales approach, they purchase their supplies through the local branches of the NGOs running the programme and then keep a portion of the retail markup, giving them an incentive to visit more households and conduct follow-ups.

Households visited by a Living Goods/BRAC health promoter were 5% more likely to have their water treated before drinking it and their children were 13% more likely to have slept under an insecticide-treated bed net. Homes with a newborn were also 71% more likely to get a follow-up visit in the first week after birth.

Commenting on the significance of the findings, Assistant Professor in Economics at Trinity,Dr Guariso, said:

Our results provide two important lessons. The first is that by strengthening simple and basic healthcare provision it is possible to achieve dramatic improvements in health outcomes. The second is that we can do that at relatively low cost.

As a business model, direct sales are not without controversy. Companies such as Herbalife and Amway have been accused of operating like pyramid schemes, exploiting their networks of salespeople by charging excessively high wholesale prices instead of relying on revenue from retail sales.

However, there was no evidence that Living Goods health promoters or patients were being charged excessively high prices, nor that product quality was substandard.

The programme has been rolled out in other countries including Kenya, Zambia, and Myanmar.

It should be stressed that the impact of the Community Health Promoter programme was conditional on existing facility-based professional health care, as availability of referral services is a crucial component of the programme. The study points to the importance of integrating the programme into the existing health service provision strategy.

Dr Andrea Guariso’s co-authors were Martina Björkman Nyqvist (Stockholm School of Economics), Jakob Svensson (IIES, Stockholm University) and David Yanagizawa-Drott (University of Zurich).

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