Do Cash or Digital Payment Modalities Affect Community Health Worker Performance? - a Case Study of a Remote Refugee Settlement in Western Uganda

Overview

Journal Glob Health Action

Specialty Public Health

Date 2024 Aug 23

PMID 39175402

Authors

Michael T Wagaba

David Musoke

Charles Opio

Arthur Bagonza

Juliet Aweko

Hajarah Nakitende

Alex Mulyowa

Michael Ediau

Peter Waiswa

Elizabeth Ekirapa-Kiracho

Affiliations

Soon will be listed here.

Abstract

Background: There is inadequate evidence about the influence of digital and cash payment modalities on the performance of Community Health Workers (CHWs) in underserved communities, such as refugee settlements.

Objective: To compare the performance of CHWs when paid in cash or digitally in Kyaka II refugee settlement, Uganda.

Methods: A comparative cross-sectional mixed methods design was used. Secondary data comprising 247 CHW reports during a six-month period of cash and digital payments were analyzed using Stata v14. Eleven focus group discussions, four in-depth interviews, and ten key informant interviews were conducted among the settlement stakeholders to explore perceptions of the payment methods. Qualitative data were analyzed thematically using Atlas.ti v9.

Results: CHWs performed better when paid cash than digital payments ( = 5.28; df = 246; < 0.001). During the cash payment period, at least secondary education (APR 1.71 CI: 1.14-2.58) and having a side occupation (APR 1.58; CI: 1.13-2.21) were positively associated with performance. For digital payments, being male (APR 0.58; CI: 0.34-0.98), serving longer than 9 years (APR 0.87; CI: 0.82-0.93), and being allocated more than 60 households per month (APR 0.31; CI: 0.19-0.52) were negatively associated with CHW performance. Qualitative data revealed that most stakeholders preferred cash due to inconsistent and delayed digital payments.

Conclusion: CHWs preferred and performed better with cash payments because digital payments were associated with delays and payment shortfalls that demotivated them. Implementers should invest towards averting digital payment shortfalls in remote settings to enhance CHW motivation and performance.

References

Wanduru P, Tetui M, Tuhebwe D, Ediau M, Okuga M, Nalwadda C . The performance of community health workers in the management of multiple childhood infectious diseases in Lira, northern Uganda - a mixed methods cross-sectional study. Glob Health Action. 2016; 9:33194. PMC: 5122228. DOI: 10.3402/gha.v9.33194. View

Ballard M, Westgate C, Alban R, Choudhury N, Adamjee R, Schwarz R . Compensation models for community health workers: Comparison of legal frameworks across five countries. J Glob Health. 2021; 11:04010. PMC: 7916445. DOI: 10.7189/jogh.11.04010. View

Colenbrander S, Birungi C, Mbonye A . Consensus and contention in the priority setting process: examining the health sector in Uganda. Health Policy Plan. 2014; 30(5):555-65. DOI: 10.1093/heapol/czu030. View

Pascal Saint-Firmin P, Diakite B, Ward K, Benard M, Stratton S, Ortiz C . Community Health Worker Program Sustainability in Africa: Evidence From Costing, Financing, and Geospatial Analyses in Mali. Glob Health Sci Pract. 2021; 9(Suppl 1):S79-S97. PMC: 7971366. DOI: 10.9745/GHSP-D-20-00404. View

Singh D, Negin J, Otim M, Orach C, Cumming R . The effect of payment and incentives on motivation and focus of community health workers: five case studies from low- and middle-income countries. Hum Resour Health. 2015; 13:58. PMC: 4501095. DOI: 10.1186/s12960-015-0051-1. View

Kasteng F, Settumba S, Kallander K, Vassall A . Valuing the work of unpaid community health workers and exploring the incentives to volunteering in rural Africa. Health Policy Plan. 2015; 31(2):205-16. PMC: 4748129. DOI: 10.1093/heapol/czv042. View

Alam K, Khan J, Walker D . Impact of dropout of female volunteer community health workers: an exploration in Dhaka urban slums. BMC Health Serv Res. 2012; 12:260. PMC: 3464156. DOI: 10.1186/1472-6963-12-260. View

Glenton C, Javadi D, Perry H . Community health workers at the dawn of a new era: 5. Roles and tasks. Health Res Policy Syst. 2021; 19(Suppl 3):128. PMC: 8506082. DOI: 10.1186/s12961-021-00748-4. View

Olaniran A, Smith H, Unkels R, Bar-Zeev S, van den Broek N . Who is a community health worker? - a systematic review of definitions. Glob Health Action. 2017; 10(1):1272223. PMC: 5328349. DOI: 10.1080/16549716.2017.1272223. View

10.

Miller N, Richards A, Marx M, Checchi F, Kozuki N . Assessing community health worker service delivery in humanitarian settings. J Glob Health. 2020; 10(1):010307. PMC: 7100867. DOI: 10.7189/jogh.10.010307. View

11.

Eluka N, Morrison S, Sienkiewicz H . "The Wheel of My Work": Community Health Worker Perspectives and Experiences with Facilitating Refugee Access to Primary Care Services. Health Equity. 2021; 5(1):253-260. PMC: 8082038. DOI: 10.1089/heq.2020.0150. View

12.

Ehiri J, Gunn J, Center K, Li Y, Rouhani M, Ezeanolue E . Training and deployment of lay refugee/internally displaced persons to provide basic health services in camps: a systematic review. Glob Health Action. 2014; 7:23902. PMC: 4185139. DOI: 10.3402/gha.v7.23902. View

13.

Champagne C, Rajkumar A, Auxila P, Perrone G, Plotz M, Young A . Improving access to care and community health in Haiti with optimized community health worker placement. PLOS Glob Public Health. 2023; 2(5):e0000167. PMC: 10022239. DOI: 10.1371/journal.pgph.0000167. View

14.

Busza J, Dauya E, Bandason T, Simms V, Dziva Chikwari C, Makamba M . The role of community health workers in improving HIV treatment outcomes in children: lessons learned from the ZENITH trial in Zimbabwe. Health Policy Plan. 2018; 33(3):328-334. PMC: 5886269. DOI: 10.1093/heapol/czx187. View

15.

Kambarami R, Mbuya M, Pelletier D, Fundira D, Tavengwa N, Stoltzfus R . Factors Associated With Community Health Worker Performance Differ by Task in a Multi-Tasked Setting in Rural Zimbabwe. Glob Health Sci Pract. 2016; 4(2):238-50. PMC: 4982248. DOI: 10.9745/GHSP-D-16-00003. View

16.

Feroz A, Jabeen R, Saleem S . Using mobile phones to improve community health workers performance in low-and-middle-income countries. BMC Public Health. 2020; 20(1):49. PMC: 6958627. DOI: 10.1186/s12889-020-8173-3. View

17.

Ballard M, Montgomery P . Systematic review of interventions for improving the performance of community health workers in low-income and middle-income countries. BMJ Open. 2017; 7(10):e014216. PMC: 5665298. DOI: 10.1136/bmjopen-2016-014216. View

18.

McNutt L, Wu C, Xue X, Hafner J . Estimating the relative risk in cohort studies and clinical trials of common outcomes. Am J Epidemiol. 2003; 157(10):940-3. DOI: 10.1093/aje/kwg074. View

19.

Russo G, Xu L, McIsaac M, Matsika-Claquin M, Dhillon I, McPake B . Health workers' strikes in low-income countries: the available evidence. Bull World Health Organ. 2019; 97(7):460-467H. PMC: 6593336. DOI: 10.2471/BLT.18.225755. View

20.

Kuule Y, Dobson A, Woldeyohannes D, Zolfo M, Najjemba R, Edwin B . Community Health Volunteers in Primary Healthcare in Rural Uganda: Factors Influencing Performance. Front Public Health. 2017; 5:62. PMC: 5372810. DOI: 10.3389/fpubh.2017.00062. View