Do cash or digital payment modalities affect community health worker performance? - a case study of a remote refugee settlement in Western Uganda.

ABSTRACT

BACKGROUND: There is inadequate evidence about the influence of digital and cash payment modalities on the performance of Community Health Workers (CHWs) in underserved communities, such as refugee settlements. OBJECTIVE: To compare the performance of CHWs when paid in cash or digitally in Kyaka II refugee settlement, Uganda. METHODS: A comparative cross-sectional mixed methods design was used. Secondary data comprising 247 CHW reports during a six-month period of cash and digital payments were analyzed using Stata v14. Eleven focus group discussions, four in-depth interviews, and ten key informant interviews were conducted among the settlement stakeholders to explore perceptions of the payment methods. Qualitative data were analyzed thematically using Atlas.ti v9. RESULTS: CHWs performed better when paid cash than digital payments (t = 5.28; df = 246; p < 0.001). During the cash payment period, at least secondary education (APR 1.71 CI 1.14-2.58) and having a side occupation (APR 1.58; CI 1.13-2.21) were positively associated with performance. For digital payments, being male (APR 0.58; CI 0.34-0.98), serving longer than 9 years (APR 0.87; CI 0.82-0.93), and being allocated more than 60 households per month (APR 0.31; CI 0.19-0.52) were negatively associated with CHW performance. Qualitative data revealed that most stakeholders preferred cash due to inconsistent and delayed digital payments. CONCLUSION: CHWs preferred and performed better with cash payments because digital payments were associated with delays and payment shortfalls that demotivated them. Implementers should invest towards averting digital payment shortfalls in remote settings to enhance CHW motivation and performance.

Main findings: Regarding the influence of payment modalities on Community Health Workers' performance, this study found that community health workers were motivated to perform better when paid with cash compared to digital payments.Added knowledge Cash payments offer better reliability than digital payments in refugee settlements, which underscores the need to understand further the barriers to digital payments, particularly in hard-to-reach areas.Global health impact for policy and action Health systems adapting to digital payments should consider a gradual transition through a hybrid approach that includes cash and digital payments while addressing the challenges associated with digital payments, especially in refugee settings and similar resource-constrained contexts.