Could digitizing payments for healthcare workers improve immunization campaigns in sub-Saharan Africa? - updates on studies funded by the Bill and Melinda Gates Foundation

The burden of Vaccine-preventable diseases (VPDs) and associated outbreaks remain a major threat to populations across Africa. Over 30 million children below the age of five are affected by VPDs and more than half a million of these die every year - representing 58% of the global VPD related deaths. Immunization is the cornerstone for controlling VPDs and has been impactful in averting over 4 million deaths every year associated with; Polio, Measles, Hepatitis B, Yellow fever and the likes (WHO AFRO report accessed at https://www.afro.who.int/health-topics/immunization)

Quality and coverage of immunization campaigns in SSA, what is the gap?

Countries in Sub-Sharan Africa (SSA) have for a long time invested in immunization campaigns to ensure population immunity against VPDs. However,       implementation of these immunization campaigns is a complex and challenging process that requires continued investment. Several challenges remain in reaching immunization targets across Africa. These include; limited access to immunization services, inaccurate and untimely compensation of immunization frontline workers, and the most recent challenge of sustaining routine immunization as part of essential health services during the COVID-19 pandemic and the Ebola outbreak in Uganda. When frontline polio health campaign workers are not compensated in a timely manner or completely, there are       serious negative effects. Campaign worker retention becomes diffcult due to unmotivation to work without pay and eventually affects the success of campaigns. More innovative ways are needed to strengthen health systems and improve immunization quality and coverage. Digitalizing payments for campaign health workers is one of such initiatives that should be further explored to bridge this gap.

The future of digital payments research: new and upcoming studies in SSA

In response to these challenges, SSA countries with support from World Health Organisation (WHO) Afro and funded by the  Bill and Melinda Gates  Foundation embarked on digitalizing the payment of healthcare workers in an effort to improve the quality and coverage of polio campaigns under the Digital Health Payments Initiative and Research project (DHPI-R). So far, 16 countries including; Cote de d'Ivoire, Conazzaville, DRC, Gambia, Ghana, Liberia, Malawi, Mali, Kenya, Tanzania, Uganda, Nigeria, Sierra Leon, South Sudan, Cameroon, and Algeria have been supported through the WHO digital payment system since 2020. 

The system involves working with local mobile money operators or banks, based on the preferences of the countries. They also work with partners and the Ministry of Health, a key stakeholder in this, to design country-appropriate intervention strategies. (SCIDaR Research Brief  2023).Since the program started, over 200,000 frontline campaign health workers have been paid through digital payments platforms such as mobile money.       Recent studies in Mali, Nigeria, Cote de d'Ivoire, and our landscape analysis provide evidence that digitizing payments for health care workers is an opportunity to further strengthen healthcare systems in SSA and has increasingly become the preferred mode of the payment for health care workers due to its added advantage of curtailing leakage of health system funds and enhancing health worker motivation.  Frontline health workers often lack bank accounts making digital payments through mobile money, a more convenient and accessible way to receive payment on time with minimal physical cash handling. Furthermore, digital payments can improve the efficiency and transparency of payment processes, by providing a digital record of transactions that can be audited and tracked and in the long run, this can help to reduce administrative costs and ensure that campaign health workers are paid accurately and on time.

As quoted by Barbara Jordan, “for all its uncertainty, we cannot flee the future”. Digital payments are the future. As shared above, there are registered successes in using digital payments for frontline health workers but there is still a need  to understand the dynamics surrounding these payments better to inform policies and scale-up of the digital payments systems in SSA. The Digital Health Payments Initiative and Research project (DHPI-R) has therefore funded several studies to collect more rigorous and empirical evidence on the effectiveness and cost-benefit of digitizing payments for healthcare workers, specifically, those involved in vaccination campaigns in the previously mentioned countries. The project will advance knowledge, build capacity and enhance reciprocal learning in the field of digital payments for immunization campaign health workers.As part of the project, up to 24 studies (including an RCT) are being conducted in both Anglophone and Francophone countries. The studies offered grants include; Six student-led studies as part of capacity building in the Anglo and Francophone hub, and 18 expert-led studies.

Investing in future scientists: Student-led studies    

The six student-led studies are short-term (lasting 6 months) with funding of up to 5000 US dollars per study. These studies are currently in the final stages of implementation and have explored various components of digital payments in Uganda and Senegal such as      acceptability, preferences, health worker experiences associated with digital payments, and performance associated with digital payments versus cash payments. The study outputs will include; blogs, manuscripts and research and policy briefs. The studies are summarized in Table 1 below. 

Principal Investigator(s)	Institution	Topic	Study design & site	Status
Patrick albert ipola	Makerere University School of Public Health (MAKSPH)	Acceptability of Digital Payments to Village Health Teams during Health Campaigns in Kumi District, Uganda	A mixed methods study in Kumi District, Uganda.	Finalysing data analysis and reporting
Priscilla Namuyonga, Geofrey Mutole	Makerere University School of Public Health (MAKSPH)	Usability of Digital Payment methods among Health Workers in National Referral Hospitals in Kampala, Uganda	Cross- sectional study in five National Referral Hospitals- Uganda	Finalysing data analysis and reporting
Michael T. Wagaba	Makerere University School of Public Health (MAKSPH)	Performance and associated factors of Community Health Workers (CHWs) incentivized using cash and digital payment methods in the Kyaka II refugee settlement.	Comparative cross-sectional study in Kyegegwa district, Uganda	Reporting and manuscript development
Veronica Kembabazi, Arnold Tigaiza	Makerere University School of Public Health (MAKSPH)	Adoptaility of Digital Payments for Community Health Workers in Wakiso district, Uganda	Mixed methods study in Wakiso district, Uganda	Finalysing data analysis and reporting
Dr El Hadji Cheikh Abdoulaye DIOP	Universite Cheikh Anta Diop (UCAD) Senegal	Knowledge, attitudes, practices and acceptability of digital payment by health workers in Senegal: a survey in the health districts of koumpentoum	A mixed methods study in Koumpentom, Senegal	Started data analysis and reporting
Pape Latyr FAYE	Universite Cheikh Anta Diop (UCAD) Senegal	Knowledge, attitudes, practices and acceptability of digital payment by health workers in Senegal: a survey in the health district of Fatick	A mixed methods study in Fatick, Senegal	Started data analysis and reporting

Table 1: A summary of the ongoing Student-led studies funded by BMG Foundation

Expert-led studies

The expert-led studies range from short, mid-term to long-term (6 months, 9 months and 12 months respectively) with funding of 70,000, 150,000 and 250,000 US dollars respectively. These include the following      :

• A landscape analysis of the local context, challenges, and opportunities for digitized payment in eight countries in Sub-Saharan Africa (SSA) including four Anglophone (Uganda, Nigeria, Ghana, and Kenya) and four Francophone countries (Cote d’Ivoire, Cameroon, Senegal, and DRC).

• A randomized controlled trial titled “Effectiveness of mobile money payments to campaign health care workers participating in the polio mass vaccination campaign:  A cluster randomized controlled trial”. This is led by a team at Makerere University School of Public Health (MAKSPH), Uganda,      

• Two studies on acceptability, satisfaction and adoptability ofdigital payments led by Universite Cheikh Anta Diop (UCAD) Senegal

• An observation study in Malawi focused on Implementation experiences of digital payments, readiness to adapt, financial inclusion, financial behavior, gender influence and impact of digital financial services on immunization health workers’ motivation, performance and retention. A study led by Compelling works limited in collaboration with University Kamuzu Health Sciences, Malawi.      

All these studies are in their final stages of implementation and we anticipate several publications, manuscripts, research and policy briefs that will be disseminated accordingly.

More studies commissioned

We received 67 applications and after a rigorous expert review, six top studies were selected and funded under the category of 100,000 US dollars for nine months. Three of these were from the Anglophone and the other three were from the Francophone region. These studies are in their initial stages of implementation and focus on: Implementation experiences of digital payments, readiness to adapt digital payment, financial inclusion, financial behavior, gender influence, and impact of digital financial services on immunization health workers’ motivation, performance, and retention in SSA. Table 2 below summarizes the expert-led studies.

Principal Investigator (PI)	Institution	Topic	Study design & site	Status
Dr.  Vincent M. Kiberu	Makerere University School of Public Health	Landscape analysis in eight (8) countries - to understand the local context, challenges, and opportunities for digitized health in eight countries in Sub-Saharan Africa.	An explorative study design with mixed methods conducted in Uganda, Nigeria, Kenya Ghana, Ivory Coast, DRC, Senegal, and Cameroon	Finalizing the reports and writing manuscripts and briefs
Dr. Victoria Nankabirwa	Makerere University School of Public Health	Effectiveness of mobile money payments to campaign health care workers participating in the polio mass vaccination campaign:  A cluster randomized controlled trial	Randomised Controlled Study in Uganda	Collecting and analyzing data
Prof. Mwapasa Victor, Dr. Simon Ndira	Kamuzu University of health Sciences, Malawi Compelling works limited,	Implementation experiences of digital payments, readiness to adapt, financial inclusion, financial behavior, gender influence and impact of digital financial services on immunization health workers’ motivation, performance and retention	Observation study in Malawi	Finalizing the reports and writing manuscript
Dr Amadou Ibra Diallo	Universite Cheikh Anta Diop (UCAD) Senegal	Evaluation of perceptions and Satisfaction with current Payment methods and acceptability of digital payment among health workers in Senegal to strengthen the health system	Mixed methods study in Senegal	Preparing protocols to submit for ethical approval
Dr Jean Augustiin Diégane Tine	Universite Cheikh Anta Diop (UCAD) Senegal	Use of digital payments during the chemoprevention campaign of seasonal malaria in Senegal, operational research	Mixed methods study in Senegal (Kolda, Kédougou,Tamba)	Preparing protocols to submit for ethical approval
Dr. Simon Ndira	Compelling Works Limited	Assessing the extent to which Digital Financial Services (DFS) affects financial inclusion, financial behavior of health workers and their households; and influence the safety and security of payments (Polio Campaign workers)	Cross-sectional study design with a mixed methods approach in Malawi	Submitted protocols and awaiting feedback from the Ethical Review Board
Dr. Joan P Kabayambi	AFRISLUM	Exploring Implementation Experiences and Readiness to adapt Digitized Payment of Community Health Workers: A case study of Benin and Uganda.	Exploratory case study design using qualitative method in Uganda and Benin	Submitted protocols and awaiting feedback from the Ethical Review Board
Prof. Olufunmilayo I Fawole	University of Ibadan	Influence of Digital Financial Services on Health Program Outcomes, Health Workers’ Motivation, Performance, Retention and Financial Behavior in Nigeria (immunization focused)	Mixed methods study in Nigeria	Submitted protocols and awaiting feedback from the Ethical Review Board
Dr. Petronille Acray-Zengbe	Enseignant chercheur  (Université Felix Houphouët Boigny, Institut National de Santé Publique)	Evaluation of digital payment for health workers in vaccination campaigns in Ivory Coast	A mixed methods study in Ivory Coast	Preparing protocols to submit for ethical approval
Dr. Niragira Juste Ntawuyamar	Hôpital Espoir de Kibuye: Centre Hospitalo-Universitaire de l’Université Espoir d’Afrique (PAACS)	Digital financial services in the health sector in Burundi:  A source of improvement in health care and a promoter of behavioral change among health personnel.	A mixed methods study in Burundi	Preparing protocols to submit for ethical approval
Dr. Mandana Arabi, Elliott Collins	Innovations for Poverty Action (IPA) and Nutrition International (NI)	Digital Payments for Integrated Child Health Days: Impacts on Health Workers in Togo	A cluster randomized trial in Togo	Preparing protocols to submit for ethical approval

Table 2: A summary of the ongoing Expert-led studies funded by BMG Foundation

Looking ahead

The success of digitization of payment for health workers is an integral process involving many actors both in the public and private sectors that influence the payment system at different stages from the development of policies to the implementation of the programs. Despite the benefits of digital payments, the findings from our landscape studies reveal that implementation is challenging for large numbers of people and in rural particularly hard-to-reach areas. Some of the crossing-cutting challenges in implementing digital payments in SSA include: delays in payments due to cumbersome verification processes, lack of trust in the system, centralization of the payment system causing errors and unmet transactional costs. Widespread availability of digital pay points throughmobile banking, debit cards, Point of Sale, mobile payment applications, Visa Interswitch, and electronic wallets provide greateropportunities for digital payments in health programs. However, interoperability of the various platforms remains a major problem that needs to be solved. Moreover, more research is needed to investigate financial inclusion, inequalities in access to digital financial services and the interrelationship between policies and practices in immunization and those that govern digital systems.  

In conclusion, through the DHPI-R project, we expect to address the gaps above and generate contextually relevant evidence of digitizing health worker payments in SSA to directly inform operations, policy, collaborations and future campaigns.       

Contact Information
Prof. Peter Waiswa- Project director ( pwaiswa@musph.ac.ug)
Dr. Elizabeth Ekirapa – Anglophone hub principal investigator (ekky@musph.ac.ug)
Prof. Adama Faye- Francophone hub principal investigator (adamafaye94@gmail.com)