A female healthcare worker

Article by Judith Grace Amoit & Maggie Ashaba

The digital age has brought about significant transformations across various sectors, including healthcare, in Sub-Saharan Africa (SSA). One key area where this transformation is making a significant impact is enabling digital payments for campaign health workers who offer lifesaving immunisation and vaccination services. 

From September 2020 to January 2023, Wakiso District,  18.22 kilometers from the Capital of Uganda, conducted several crucial vaccination campaigns against COVID-19, Polio, and Measles-Rubella. Initially, these campaigns relied on traditional cash payments, which posed significant challenges. Delayed payments and logistical hurdles created a backlog that caused disruption and dissatisfaction among the health workers.

Dr. Mathias Lugoloobi, the District Health Officer (DHO) of Wakiso district, witnessed firsthand the challenges associated with cash payments in vaccination campaigns and recognised the need for a more efficient and transparent mode.   

The Transition to Digital Payments

Between February 2021 and June 2022, Wakiso District began the transition to digital payments for healthcare workers involved in vaccination campaigns, working with  implementing partners such as IDI (Infectious Disease Institute), UNICEF, and EPIVAC, supported by the  Ministry of Health .

From June 2022 onwards, payments to vaccination campaign workers in the district were made by the government of Uganda through E-Cash - a cashless payment system- launched by the Ministry of Finance Planning and Economic Development (MoFPED). 

This timely change brought forth numerous benefits for Wakiso District's immunization campaigns. One significant impact was the reduction in the likelihood of fraud, as fewer intermediaries were involved in money transfers. Moreover, transaction costs decreased, allowing healthcare providers to reach rural populations more effectively and expand their services to cover larger areas.

Benefits Reaped

Mr. Micheal Nsimbi, the wakiso district campaign supervisor confirmed that through this newly adopted payment scheme, campaign health workers in Wakiso received their compensation wholly and in a timely manner. Additionally, the districts' managers benefited from one of the digital payment system’s unique inbuilt features, which enabled the creation of a financial audit trail, simplifying the immunization program funds accountability and auditing process. 

By automating this previously paper-based process, it has alleviated related pressures and reduced errors thus enhancing transparency in the health department enhancing data collection, auditing, and transparency.

In view of these vantage points, Dr. Matthias retorted the importance of building trust and change, he emphasized that embracing change and building trust among healthcare workers were essential in successfully transitioning to digital payment systems.

Not without challenges  

Like all changes, the transition to cashless payments was not shy of challenges. Health workers at the grassroots decried overdue payments which, according to Dr. Mathias, were a result of prolonged verification processes.  In some instances, officials responsible for such processes were unavailable to perform these tasks.

Furthermore, the payment process was significantly burdened by rigid beneficiary authentication requirements, which necessitated individuals supporting the campaigns during that period to provide Tax Identification Numbers (TIN) upon registration. 

Additionally, delays in the processing of requisitions from Wakiso District to the central level by the Ministry of Finance, Planning, and Economic Development Uganda further impeded timely payment to campaign workers at the district level.

Due to these delays, supervisors resorted to using their own savings to pay out allowances in order to keep the health workers motivated.

In numerous instances where e-payment was utilized, health workers encountered difficulties in categorizing the received payments as compensation for their work during different vaccination campaigns. This issue arose due to the payment system's failure to provide a detailed payment description, clearly indicating the specific activity for which the funds were received. As a result, it became challenging for the health workers to accurately account for their earnings.  However, these challenges provided valuable insights for improving the system further.

Lessons learnt 

Wakiso District's transformation from cash to digital payments in immunization campaigns showcases the vast potential and positive impact of embracing digital payments in healthcare. By streamlining transactions, reducing fraud, and enhancing transparency in the case of Wakiso district, digital payments have the potential to improve the efficiency and effectiveness of vaccination campaigns across all settings if all infrastructure needed  is in place.

Looking ahead, Wakiso District serves as an exemplary model for other regions in sub-Saharan Africa considering similar transitions to digital payments. Continued collaboration, proper training, and addressing infrastructural barriers are crucial to successful adoption.

Dr. Lugoolobi says government-led programs, partnerships with mobile network operators, and collaborations with financial institutions play a crucial role in narrowing the digital payment gap. Initiatives such as providing training, affordable smartphones, and accessible digital payment platforms are essential steps to enhance healthcare accessibility.

Additionally, the success of digital payments in Wakiso District highlights the possibility of scaling up such initiatives across sub-Saharan Africa. Continued investments, increased digital literacy, and collaborations will further enhance inclusivity and improve immunization coverage and outcomes in the region.

From the above experience, the Digital Health Payment Initiative and Research in Africa (DHPI-R) comes into play in a way that its involvement in the Wakiso District's journey showcases the importance of research, collaboration, capacity building, and policy advocacy in promoting the adoption of digital health payment solutions through their community of practice.

Its contributions are crucial in driving positive changes in healthcare systems, enhancing efficiency, transparency, and accessibility in vaccination campaigns and beyond.