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Digital Health Pilot Project in Uganda Extends the Reach of Family Planning Care in the Community

Living Goods shares experiences from a pilot project where community health workers (CHWs) used digital health technology to advance access to family planning care at the community level. CHWs are a critical component of any strategy to bring health services closer to people. The piece calls on policy makers and technical advisors to sustain investments in the digitization of community health programs to reduce unmet need for family planning.

Uganda has one of the highest population growth rates in the world. Although the total fertility rate has declined from an average of 6.9 births per woman in 2000 to 5.4 births per woman in 2016 (2016 Uganda DHS), it remains among the world’s highest. At the current growth rate, Uganda’s population is expected to double every 20 years and the total population is estimated to reach 100 million by 2050. Only 35% of women in Uganda use modern contraceptive methods, and unmet need for family planning is 28% (2016 Uganda DHS). The burden of unintended pregnancy and its consequences disproportionately fall on poor women and girls, impacting family health and challenging the ability of women and families to manage resources and secure education.

The low rate of family planning uptake and high unmet need for family planning provide an opportunity for community health workers (CHWs) to offer education and care to their communities. The Government of Uganda, through the Investment Case for Reproductive, Maternal, Neonatal, Child and Adolescent Health (RMNCAH) Sharpened Plan for Uganda (2016/17–2019/20), recognizes the important role CHWs (known as Village Health Teams, or VHTs) play in providing treatment and linking communities to health facilities for advanced care.

Intervention: Use of Digital Health Tools to Improve Access to Family Planning

Living Goods uses technology to provide an integrated health package that addresses RMNCAH needs. In particular, Living Goods provides CHWs with digital tools to support CHWs as they diagnose and treat health conditions, improve their reporting, and use data for performance management. In 2017, Living Goods deployed a phased approach to test a comprehensive family planning strategy, which trained and equipped CHWs to provide family planning counseling and short-acting methods including the injectable DMPA-SC (Sayana Press), emergency contraceptive pills (ECPs), combined oral contraceptives (COCs), and the progesterone-only pill (POP) for breastfeeding mothers. The CHWs also referred clients in need of long-acting and permanent methods to identified service delivery points.

The program was implemented in two districts—Wakiso and Mpigi—starting initially with 30 CHWs in each branch and rolling out to all 200 eligible CHWs. CHWs were already using the Smart Health application for maternal and child health services delivery, and Living Goods added family planning workflows in the digital application to support CHWs’ provision of family planning counseling and care. Each CHW received a phone loaded with the Smart Health digital application, which is designed with workflows to standardize client counseling, assessment, and administration protocols for family planning care. This enabled CHWs to accurately educate clients, determine their eligibility for family planning, recommend an appropriate method, and provide follow-up services. The Smart Health app generates task reminders for CHWs to follow up and advise family planning clients, should they experience any side effects. Reminders are also generated for clients who may be due for refills, require follow-up counseling, or have been referred for long-acting methods. This ensures the CHWs’ delivery is efficient and effective.

CHW supervisors also have access to their own supervisor app, where they can see real-time performance data for every CHW and use analytics dashboards to monitor and drive better performance, and ultimately, impact. All the data generated through these mobile health tools is shared with the government and used to inform decision-making for CHW programs at every level.

In Kasanje, Wakiso district, Uganda, a VHT educates a young woman about different modern methods of family planning, with the support of the SmartHealth app. Photo: Phionah Katushabe/Living Goods
In Kasanje, Wakiso district, Uganda, a VHT educates a young woman about different modern methods of family planning, with the support of the SmartHealth app. Photo: Phionah Katushabe/Living Goods
In Iganga district, Uganda, a VHT educates women about modern family planning methods.  Photo credit: Phionah Katushabe/Living Goods 
In Iganga district, Uganda, a VHT educates women about modern family planning methods.  Photo credit: Phionah Katushabe/Living Goods 

Results of Digital Health Pilot Intervention

Results showed that 56% of the clients visited by a CHW took up family planning every month throughout the life of the pilot (May 2017 to June 2018). The number of women provided with a family planning method per CHW per month also grew, from 2.4 in May 2017 to 6.7 by June 2018. In the same period, the number of new contraceptive users per CHW rose modestly, from less than 0.9 per month to 1.2, and half of the women who had not previously used family planning started using a method after receiving counseling from a CHW. . DMAP-SC was the most preferred method offered by the CHWs, while clients referred for long-acting methods preferred implants.

Furthermore, introduction of contraceptives into the service basket led to overall improvement in CHW performance. For example, in one of the divisions in Wakiso district, CHWs providing a combination of family planning, immunization, and integrated community case management (ICCM) services visited 10 additional unique households per month (from 36 in August 2019 to 46 in November 2019) and treated 7 more sick children per month as compared with their colleagues delivering only ICCM and immunization services (Figure 1). Contrary to the initial expectations by the project team regarding integrating services provided by CHWs which would have derailed their motivation due to work overload, a key learning is that CHWs were highly motivated referring and providing other services. In addition, the CHWs are treating 17 sick children every month as opposed to 10 sick children when implementing the core ICCM module alone.

Average number of unique households visited per CHW in Masajja Division, Wakiso District, Uganda
Figure 1: Average number of unique households visited per CHW in Masajja Division, Wakiso District, Uganda

Conclusion

Adding family planning to CHW responsibilities, supported through the Smart Health digital app, enabled CHWs to improve access to modern contraception while accurately delivering family planning care. The success of this pilot gave birth to a larger-scale family planning program in 19 districts of Uganda. The increased contraceptive uptake demonstrates what would have been a missed opportunity if CHW work was not amplified through the use of technology. This shows the potential of digital community health platforms to provide high-impact, low-cost solutions to health systems challenges and reduce inequities in access to care. It is therefore worthwhile for government (policy makers) and implementing partners (technical advisors) to continue investing in the digitization of community health programs to reduce the unmet need for family planning services.

Members of the Living Goods organization
Allan Eyapu

Senior Field Operations Manager

Allan has over 10 years of experience in the health sector, designing, implementing and evaluating social impact programs. Some of his previous assignments include shaping private sector markets to expand access to essential child medicines, supporting Ministry of Health to introduce and integrate new family planning commodities into the national supply chain system, and leading capacity building efforts for grassroots service delivery partners on logistics management. In his present role, he develops and rolls out relevant tools, processes and systems to drive performance and effectiveness of the community health workforce.

Frank Namugera

Health and Impact Analyst

Frank Namugera is a statistician and a data scientist currently working with Living Goods Uganda as a Health and Impact Analyst – Monitoring and Evaluation. He is passionate about using data and statistical models to inform and aid decision making in the health sector to improve U5, maternal and reproductive health.​

Phionah Katushabe

Communications Manager

Katushabe is a passionate storyteller and communications specialist with over nine years of experience designing and implementing communication strategies with national and international development organisations, to contribute to health system strengthening. She leads teams in content creation (writing and photography), media relations, facilitating trainings, digital media management, and supporting programmes to design BCC messages in different social cultural settings. Katushabe has a master’s degree in International Social Development.​

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