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Presented By: International Policy Center

Working With Community Health Workers to Increase Use of ORS and Zinc to Treat Child Diarrhea In Uganda: A Cluster Randomized Controlled Trial

David I. Levine, University of California, Berkeley

Authors: Zachary Wagner, John Bosco Asiimwe, William H. Dow, David I. Levine

Diarrhea remains the second leading cause of death among children, although nearly all deaths could be prevented with the use of oral rehydration salts (ORS). There is little evidence demonstrating why ORS use remains low and what can be done increase use. Although community health workers (CHWs) are often tasked with increasing ORS use, little is known about how CHWs should distribute these products to maximize coverage. We hypothesized that price and lack of convenience are important barriers to ORS use, and therefore examined two key features of ORS distribution: 1) charging vs. free distribution and 2) home delivery vs. client retrieval. We used a village-clustered randomized design across 118 villages in Uganda to experimentally vary the price and convenience of accessing ORS from CHWs. Villages were randomized to one of four groups: 1) a novel preemptive home delivery intervention (Free+Delivery) made ORS free and conveniently available inside the home when a child came down with diarrhea; 2) a preemptive home sales intervention (Home Sales) made accessing ORS conveniently available at the home, but not free; 3) a free upon retrieval intervention (Vouchers) made ORS free but not convenient; 4) a control group had CHWs carry out their normal activities. This design allowed us to evaluate the impact of competing CHW distribution strategies as well as to examine the causal effect of price (Free+Delivery vs. Home Sales) and convenience (Free+Delivery vs. Vouchers) on ORS use. The first result is that Free+Delivery increased the share of cases treated with ORS by 21 percentage points (36%) relative to the control group. Second, Free+Delivery increased ORS use by 12 percentage points (18%) relative to Home Sales, suggesting that price is an important barrier to use. Third, we found no evidence that convenience was an important barrier. Free+Delivery did not do a worse job of targeting higher risk cases or lead to increased wastage relative to the other groups. Moreover, Free+Delivery was extremely cost effective from a donor perspective at only $64 per DALY averted, relative to the status quo. The results suggest that price is an important barrier to ORS use in Uganda, that substantial gains in ORS coverage can be made if CHWs distribute the products for free as opposed to charging, and that free distribution is highly cost effective.

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