By: Zachary Wagner (1), John Bosco Asiimwe (1), William H. Dow (1), and David I. Levine (1)
Diarrhea is one of the leading causes of death among children under age 5 (Omana et al., 2020). Although ORS is a well-known treatment for diarrhea, fewer than half of children with diarrhea in poor nations receive ORS. We describe a study we conducted in Uganda in 2017 using community health workers (CHWs) to increase ORS use (Wagner et al., 2019; Wagner, Asiimwe, and Levine, 2020).
Uganda, like other nations, uses community health workers to increase access to essential health products such as ORS and Zinc. There is substantial variation in how public and NGO CHW programs operate. For example, some programs charge for health products, whereas others distribute products for free. Some CHWs distribute products to clients through home delivery, whereas others require that caretakers retrieve ORS or other products. Unfortunately, there is little evidence about which program types increase use of ORS.
We worked with BRAC CHWs to measure the importance of price and inconvenience as barriers to ORS use. To do these tests, we randomized 188 villages (and CHWs) into 4 groups:
- In arm 1, CHWs delivered free ORS and zinc before any child was ill. Thus, free ORS and zinc were already conveniently available inside the home when a child came down with diarrhea. We instructed CHWs to deliver ORS and zinc for free to all households with a child under five years of age at the beginning of the study period.
- In this arm CHWs created demand for ORS and Zinc by informing caretakers in advance that they were both available for free from the CHW’s home in case their child came down with diarrhea. This arm made ORS and zinc free (like arm 1), but in this arm ORS was not as convenient because the caregiver had to retrieve the ORS.
- We instructed CHWs to visit all households in their village with a child under five years of age and offer to sell ORS and zinc at the market price. A pre-illness home sales intervention made accessing ORS convenient, but not free.
- Finally, a control group had CHWs carry out their normal activities.
We invited CHWs that were assigned to arms 1, 2 or 3 to attend a short training session. We provided each CHW with sufficient free ORS to serve all of the under-5 children in their village. We asked CHWs in the Home Sales study arm to sell at the market price: 500 UGX (US$0.14) for each packet of ORS and 1,000 UGX (US$0.28) for a packet of zinc. CHWs kept all sales revenue.
Only 56% of control group cases were treated with ORS. Delivering free ORS prior to illness (arm 1) and retrieval of free ORS by the caretaker (arm 2) increased the share of cases treated with ORS by 20 and 18 percentage points, relative to the control group. Home sales prior to illness increased ORS use by 8 percentage points. Results are in Figure 1.
The likelihood of starting ORS on the first day of symptoms also increased with pre-illness delivery (by 19 percentage points) and with retrieval of ORS by caretaker (by 11 percentage points). Undesirable use of antibiotics for uncomplicated diarrhea cases was also slightly lower in arm 3, when caregivers could retrieve free ORS.
CHWs made more household visits when they distributed ORS and zinc for free (arms 1 and 2) than when charging the market price (arm 3) – even though CHWs kept all revenue with home sales. For example, CHWs in the retrieval of ORS by caretaker arm (arm 2) visited nearly 70% more households than CHWs in the home sales arm (arm 3). The findings suggest that many CHWs respond more to the opportunity to help their neighbors than to the opportunity to earn a modest amount of money.
If our results apply throughout Uganda, then implementing either free distribution (arm 1) or retrieval by caretaker (arm 2) nation-wide could avert over 1200 child deaths per year. Given the low cost of ORS, these interventions are among the most cost-effective maternal and child health interventions.
- BRAC, https://bracusa.org/brac-living-goods-uganda-health
- Omona, S., Malinga, G.M., Opoke, R. et al. Prevalence of diarrhoea and associated risk factors among children under five years old in Pader District, northern Uganda. BMC Infect Dis 20, 37 (2020). https://doi.org/10.1186/s12879-020-4770-0
- Wagner, Zachary, John Bosco Asiimwe, and David I. Levine. “When financial incentives backfire: Evidence from a community health worker experiment in Uganda.” Journal of Development Economics 144 (2020): 102437.https://www.sciencedirect.com/science/article/abs/pii/S0304387819307801?via%3Dihub
- Wagner, Zachary, John Bosco Asiimwe, William H. Dow, and David I. Levine. “The role of price and convenience in use of oral rehydration salts to treat child diarrhea: a cluster randomized trial in Uganda.” PLoS medicine 16, no. 1 (2019): e1002734. https://cega.berkeley.edu/wp-content/uploads/2020/04/The-Role-of-Price-and-Convenience-in-ORS-Use.pdf