Presentation on theme: "2015 EAST AFRICA Evidence Summit July 8-9, 2015 | Nairobi, kenya"— Presentation transcript:
1 2015 EAST AFRICA Evidence Summit July 8-9, 2015 | Nairobi, kenya 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 Dow2015 EAST AFRICA Evidence SummitJuly 8-9, 2015 | Nairobi, kenya
2 MotivationDiarrheal diseases are the second leading cause of child mortality under-5 (Liu et al. 2012)In Uganda, under 5 child mortality is 90 per Diarrhea accounts for 13% total children’s deathsDiarrhea 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).
3 BackgroundWorking with VHTs may increase use ORS, which is key in reducing under-5 mortality in UgandaIn 2001, government of Uganda established VHTs in an effort to increase ORS use and other health interventions in rural areasVHTs 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).
4 Literature Review Basinga, et al., 2010 – research on incentives WHO,2007 – essential health services cannot be provided by people working on a voluntary basisDambisya et al., 2012 – on diarrhoea case management in low income countriesWagner et al., 2014 – inconvenience for mothers/caregivers to visit the VHTs
6 InterventionVHTs are community-based and community-run health services in UgandaThey are not trained medical health workerThey work on voluntary basisThey 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
7 Structure of Uganda’s Health System Reg/National – Referral HospitalDistrict – HCIV or HospitalSub-county - HCIIIParish - HCIIVillageexpected to have2-5 VHTs. 100 HH
8 VHT Tasks/RolesCommunity 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 growthEnvironmental health: water, sanitation & hygieneBehaviour change: Promotion of healthy practices: handwashing, use treated mosquito nets, immunization
9 ChallengesHigh levels of attrition seen among VHT workers (MoH, 2013).- Villages with presence of VHTs dropped from 78% (FY2011/12) to 55% FY2012/13Attrition due to being overworked and receiving no compensation (voluntary basis)Attrition is also due to lack of medical supplies (ORS) at the health facility
10 Goal of StudyThis 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
11 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 controlSample size 1,000 households; 14 households per villageThe district conveniently likely to work with best could be selected – CEGA comment after presentation
12 TreatmentTreatment: Training + delivery of ORS+ ZINC to households with children under 5 (with financial compensation to VHTs for delivery)Control: Training of VHTs
13 Research QuestionsDoes 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?
14 Empirical Specification Yitv=δ0+Treat.Postitvδ3 +Xitvβ+Vv+uitv𝑌𝑖t health outcome for each selected HH i.e ORS use, time to ORS initiation, and whether ORS is stockedTreat is a dummy for the treated=1; 0 otherwisePost is a dummy for the intervention period i.e endline=1 and 0 otherwiseX 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-effectsu is the individual’s error term
15 Next Steps Conduct Formative Research - Work with the ministry of health, local healthofficials, village leaders, VHTs, NGOs and mothers/caregivers to craft the intervention and assessacceptance and appropriateness of incentiveEnsure political feasibility and buy-in of studyList villagesAverage pay per VHT will be 15US$ per month (figure based on village level wages); discuss possibility to offer different levels of incentives?