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 Dow
2015 EAST AFRICA Evidence Summit
July 8-9, 2015 | Nairobi, kenya

2. 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 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).

3. 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).

4. 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

5. Location of Study
Area of Study

6. 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

7. Structure of Uganda’s Health System
Reg/National – Referral Hospital
District – HCIV or Hospital
Sub-county - HCIII
Parish - HCII
Village
expected to have
2-5 VHTs. 100 HH

8. 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

9. 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

10. 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

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 control
Sample size 1,000 households; 14 households per village
The district conveniently likely to work with best could be selected – CEGA comment after presentation

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

13. 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?

14. Empirical Specification
Yitv=δ0+Treat.Postitvδ3 +Xitvβ+Vv+uitv
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

15. 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 assess
acceptance 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?