Living Goods shares experiences from a pilot project where community health workers (ACS) usaram a tecnologia digital de saúde para promover o acesso aos cuidados de planejamento familiar em nível comunitário. Os ACS são um componente crítico de qualquer estratégia para aproximar os serviços de saúde das pessoas. 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 para 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, e unmet need for family planning is 28% (2016 Uganda DHS). o 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 (ACS) 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.
Living Goods uses technology to provide an integrated health package that addresses RMNCAH needs. Em 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. Dentro 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, impacto. 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.
Results showed that 56% of the clients visited by a CHW took up family planning every month throughout the life of the pilot (Maio 2017 to June 2018). The number of women provided with a family planning method per CHW per month also grew, a partir de 2.4 in May 2017 para 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. Por exemplo, 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 (a partir de 36 in August 2019 para 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. Além disso, the CHWs are treating 17 sick children every month as opposed to 10 sick children when implementing the core ICCM module alone.
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) e parceiros de implementação (consultores técnicos) to continue investing in the digitization of community health programs to reduce the unmet need for family planning services.