Health
What works, what doesn’t work? Researchers uncover the effect of supporting districts to operationalise digital payments for vaccination campaign workers
Published
1 year agoon
By
Mak Editor
By Joseph Odoi
A motivated and satisfied health workforce is critical for the success of mass vaccination campaigns against diseases like polio. High-quality vaccination campaigns can interrupt disease transmission, especially during and after periods of disrupted health services, such as those caused by the COVID-19 pandemic.
In sub-Saharan Africa, most vaccination campaign healthcare workers (VCHWs) have historically been paid in cash. Cash payments are often plagued by delays in funds disbursement, leakages, theft risks, and limited financial transparency. These challenges can negatively affect vaccination coverage and worker satisfaction.
To address these challenges, many countries are transitioning to digital payment systems, which are perceived as faster, more convenient, traceable, reliable, and easy to implement. Digital financial systems are already being rolled out in countries including Côte d’Ivoire, Ghana, Mali, Congo, and the Democratic Republic of the Congo. Uganda, with a projected population of nearly 41.6 million, had over 30 million registered mobile money customers using e-cash in 2019.
While early rollouts of digital payments have been largely successful, their full impact on vaccination campaign workers had not been systematically evaluated.
From 2021 to 2024, Makerere University (Uganda) and the University of Dakar (Senegal), with support from the Gates Foundation and technical partners including the Solina Group, WHO AFRO, and the Ministries of Health and Finance in both embarked on an important journey of research under the Digital Health Payment Initiatives and Research (DHPI-R) Project in 28 countries in Sub Saharan Africa
To explore the experiences and lessons of polio vaccination campaign healthcare workers (VCHWs), both male and female, during the 2022 oral poliovirus vaccination campaign in Uganda, researchers led by Prof. Peter Waiswa (principal investigator), together with Margaret McConnell, Juliet Aweko, Daniel Donald Mukuye, Charles Opio, Maggie Ssekitto Ashaba, Andrew Bakainaga, and Elizabeth Ekirapa-Kiracho, with support from the Gates Foundation, conducted a study titled “The Effect of Supporting Districts to Operationalise Digital Payments for Vaccination Campaign Workers: A Cluster Randomised Controlled Trial During the 2022 Polio Vaccination Campaign in Uganda.”
This study examined whether supporting districts to implement electronic cash (e-cash) payments, instead of cash, increased e-cash usage and improved vaccine campaign healthcare workers’ (VCHWs) motivation and satisfaction during an oral poliovirus vaccination campaign in 2022 in Uganda.
The mixed method study now published in BMJ Global Health, September 2025 was conducted in 54 districts in Uganda that had set up the government e-cash payment platform by May 2022. It involved healthcare workers supporting the polio vaccination campaign, regardless of direct vaccine contact. This included nurses, clinicians (vaccinators), mobilisers, community health workers (village health team members), recorders, local council representatives, and supervisors. The unit of randomisation was the district, while the unit of enrolment and data collection was the individual worker.
Method and Setting
As part of this study , In November 2022, a total of 54 districts and 2,665 vaccination campaign healthcare workers (VCHWs) were enrolled in the study and randomly assigned to two groups. Intervention districts received training on using the government e-cash platform, including managing user roles, uploading beneficiary data, and generating payment reports.
The control districts received the standard support given to districts during mass vaccination campaigns from the MoH, MoFPED, WHO and other development partners. This support included group training on implementation of payments, provision of vaccination materials and financial aid.
The study collected data on how VCHWs were paid, their motivation, and their satisfaction with the payment method. Overall, 765 VCHWs in intervention districts and 589 in control districts received e-cash payments.
Findings
Mode of payment for the vaccination campaign healthcare workers
Overall, approximately half of the campaign workers, 50.8% (1354/2665) were paid digitally (e- cash), either using mobile money or via the bank (online supple mental table 2). Payment by e- cash was higher among females, 53.9% (656/1215) compared with males, 48.1% (698/1450) and was lowest among campaign workers aged 30–39 years, 48.7% (368/765). E- cash payment was higher in the intervention arm at 57.5% (765/1,330) in comparison to the control arm at 44.1% (589/1,335).
Satisfaction with payment received during the campaign
Only 36.5% (705/1930) of the VCHWs were satisfied with the payment received during the campaign, with satisfaction being slightly higher in the intervention arm, 37.9% (353/931) compared with the control arm 35.2% (352/999) and among females 37.9% (351/925) compared with males 35.2% (354/1005). Satisfaction was lowest among the married workers, 35.7% (575/1611) compared with the other categories.
Timing and completeness of payments
Nearly, all VCHWs were paid after the campaign, 97.6% (1884/1930), with no significant difference between the intervention (98.1%, 913/931) and the control (97.2%, 971/999) arms
Delayed/non- payment was highest among those with no formal education, 34% (17/50) and among community mobilisers, 30.7% (392/1071). The majority (70.6%, 1362/1930) of the VCHWs stated that the payment received met or even exceeded their payment expectation.
Participants also stated that e-cash was convenient, transparent, time-saving, and cost-saving, as it reduced travel and waiting times and minimized informal deductions.
Despite these benefits and support to districts to operationalize digital payments , there was no significant difference in workers’ motivation or satisfaction between the intervention and control groups. The researchers attributed this partly due to challenges associated with both cash and digital payment modes.
Challenges experienced in effecting payments at the district level
Also a number of challenges were uncovered in this study . Challenges with e-cash payments included unanticipated withdrawal charges, unreliable internet networks, and lengthy processes for validating mobile telephone numbers. For example, payments were delayed or not processed when VCHWs’ names did not match the registration details held by telecommunication companies, or when workers did not have phones registered in their names.
One key informant had this to say on challenges around e-cash payments
‘’ There was a general complaint of charges. Remember when they are dispersing funds, they stick to the budget exactly. They are not looking at the charges. And when you are also paying you have to allocate minus the charges. You get the point. So the people would be expecting let’s take an example of 150 000/= and then they get 149 something. So, they would ask, ‘Why are we getting less money?’ So we labored to explain to them that the bank is charging a certain fee to facilitate the e- cash. (KII_West_EPI FP) There were also challenges associated with an unreliable internet network that was necessary to facilitate log ins for approval of payments
On Challenges experienced in effecting payments at the district level ,Key informant interviews with district leaders involved in the payment process identified several bottlenecks during the payment process of the campaign healthcare workers. One of the major e- cash payment challenges was a lengthy process of validating mobile telephone numbers. ensuring that the VCHW’s names matched the registered mobile account names attached to the telephone number provided by the VCHW for receipt of funds.
‘’Unsuccessful validation occurred when the VCHW’s names did not match the registration details held by the telecommunication companies. Payments for such individuals were delayed or not effected at all. Because some of them do not even have the phones, but they are very good at doing the work…Or if they have, then the phone is not registered in their names. We were supposed to bring that database of the community as well and feed them into the system. That became a problem’’. (KII_North_ADHO)
Suggestions to improve use of e-cash payment system
To increase the use of e- cash, the majority of key informants identified continued training of key staff as a critical intervention with subsequent follow- up to ensure payments are well implemented.
‘’We are not yet ready; our capacity hasn’t been built. We have a big knowledge gap regarding the e- cash system here in this district. (KII East CFO) We request for more training to be conversant [with the system], and to discuss the challenges together during that training, as we share the experiences. Where we have challenges, we sit together and see how they can be addressed’’. (KII_Central_CFO)
The participants also expressed the need for feedback mechanisms to allow them to dialogue with the payers in case there was a delay in payment. Additionally, the participants also acknowledged that there was a need to gradually expand adoption of digital payments considering contextual barriers. A hybrid approach would be an alternative, especially in the remote and hard-to-reach districts.
Other suggested solutions include early preparation of campaign health worker databases to allow for the lengthy telephone validation processes, improvement of the internet infrastructure, consistent use of e- cash payments across programmes and inclusion of withdrawal charges when making payments.
Moving forward policy, the researchers recommend the need to support e- payment systems, in order to minimize challenges in the pay ment processes.
‘’Suggestions to improve the e- cash experience include training of personnel in charge of e- cash payments, timely creation of VCHWs databases, expanding e- cash payments across programmes for efficiency and inclusion of withdrawal charges for the digital payments. To ensure the institutionalisation of digital payment interventions across Uganda, several key enablers are essential. These include formal policy integration by the Ministry of Health and Ministry of Finance into operational guide lines and budget frameworks, as well as ongoing capacity strengthening at the district level to enhance digital planning, payroll management and troubleshooting. Reliable infrastructure such as mobile connectivity and access to digital financial services like mobile money must also be prioritised, especially in rural areas. Implementing routine monitoring and feedback systems will be vital for tracking payment timeliness, worker satisfaction and system performance, allowing for continuous improvement. Furthermore, fostering public–private partner ships with telecom providers and payment platforms is critical for cost- effective scaling. With strong political commitment, aligned funding and active community engagement, this model holds the potential for broader national and regional adoption, leading to more efficient and equitable health service delivery’’. The paper concludes on the way forward
To read the paper; click; https://gh.bmj.com/content/10/Suppl_4/e016666
About The DHPI-R project
The DHPI-R project was commissioned by the Bill and Melinda Gates Foundation (BMGF) to generate evidence on digital payments in Africa. Although inception, conceptualization of the proposal, and grant award were conducted earlier in 2021, the DHPIR project officially started implementing activities in November 2021, up to March 2025. DHPIR is hosted at the School of Public Health, College of Health Sciences at Makerere University and is implemented in Anglophone and Francophone hubs (countries) in Africa. The Anglophone hub is hosted at MAKSPH, while the Francophone Hub is hosted by the University of Dakar (UCAD) in Senegal.
DHP-IR was rooted in the End Polio Game Campaign, championed by WHO-Afro and partners in 28 countries in Sub Saharan Africa, where digital payments was a key strategy for timely and complete payments to campaign workers.
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Makerere University’s School of Public Health (MakSPH) showcased research, training and international partnerships supported through European Union funding during the EU Uganda Research and Study Fair 2026 held at Makerere University.
The fair brought together students, researchers, academics, government representatives and development partners to explore opportunities in education, research, innovation and international collaboration, while celebrating 50 years of partnership between Uganda and the European Union.
Through its exhibition, MakSPH highlighted research and capacity building initiatives addressing public health challenges including infectious diseases, non communicable diseases, health systems, climate change and pandemic preparedness.
18 EU funded projects supported at MakSPH
Prof. Rhoda Wanyenze, Dean of Students, School of Public Health, said the School has benefited from 18 EU funded projects over the past five years, supporting research and training across several areas of public health.

She said the projects have contributed to the training of PhD researchers and the development of research addressing infectious diseases and prevention, non communicable diseases, health systems, climate change and health.
Prof. Wanyenze also highlighted a new five year programme which started in 2021 that is aiming at strengthening capacity for research on pandemic preparedness and response, including outbreaks such as Ebola.

Another programme being undertaken with the Ministry of Health and Karolinska Institute focuses on improving maternal health while also addressing adolescent pregnancy and the health of mothers and children.
She described partnerships as critical to advancing science and innovation, noting that collaboration allows researchers in Africa and Europe to share knowledge and strengthen the impact of research on communities.
Research partnerships strengthen innovation
Prof. Robert Wamala, Director of the Directorate of Research, Innovation and Partnerships at Makerere University, said the exhibition provided an opportunity to showcase EU funded projects across the University.
He noted that the School of Public Health alone has more than 18 such projects, while other colleges also have several EU supported initiatives.

One of the projects showcased was PREPARE TID, a partnership aimed at developing rapid diagnostic technologies for emerging and re emerging infectious diseases.
Prof. Julius Okuni, Associate Professor of Veterinary Pathobiology and Molecular Diagnostics at Makerere University, said the project brings together universities, industries and other organisations from Africa and Europe.
The project is working to develop technologies that can quickly identify pathogens responsible for outbreaks such as Ebola, Rift Valley fever and Crimean Congo haemorrhagic fever.
According to Prof. Okuni, Makerere is involved in field and laboratory work to test and refine the technologies before they can be delivered to end users.
Fair provides platform for research visibility
For researchers at MakSPH, the fair also provided an opportunity to increase the visibility of ongoing research and create new connections with researchers, policymakers and potential funders.
Dr. Raymond Tweheyo, Honorary Lecturer and Senior Research Fellow in the Department of Health Policy, Planning and Management, said such exhibitions allow researchers to share their work and identify others working on related challenges.

He cited the CONNECT for Health project, which focuses on transforming non-communicable disease care in Uganda through collaboration with partners across several countries.
Dr. Tweheyo said exhibitions can help researchers connect with policymakers, civil society organisations and other partners who can contribute to translating research into practical solutions.
Assoc. Prof. Angelina Kakooza Mwesigye, Associate Professor and Child Neurologist at Makerere University College of Health Sciences, also emphasised the importance of exposing young people to international research opportunities.
She said the long standing Uganda Europe partnership provides opportunities for the next generation of researchers to learn, build networks and prepare for future research collaborations.
The School of Public Health’s participation highlighted the role of international partnerships in strengthening research capacity, supporting innovation and developing evidence based responses to Uganda’s public health challenges.
Health
Uganda’s Outbreak Experience Points to Strong Response Systems but Persistent Detection Gaps
Published
2 days agoon
October 6, 2026
Uganda has strengthened its ability to respond rapidly to Ebola and Marburg outbreaks once cases are confirmed, but delays in frontline detection, health worker exposure, emergency financing bottlenecks and incomplete implementation of lessons from previous outbreaks continue to undermine preparedness, a study has found.
The findings were presented today, October 6, 2026, during a country validation workshop convened by the Meeting Targets and Maintaining Epidemic Control (EPiC) project, to examine lessons from Uganda’s response to filovirus disease outbreaks. The study was undertaken by Makerere University School of Public Health and FHI 360.
Presented by Dr. Steven Kabwama, the synthesis examined Uganda’s experience with recurrent Ebola virus disease (EVD) and Marburg virus disease (MVD) outbreaks between 2000 and 2026, drawing particularly on After-Action Reviews from the 2017 Marburg outbreak and the 2019, 2022 and 2025 Ebola outbreaks. The work seeks to consolidate recurring strengths, weaknesses, innovations and lessons that had previously been documented separately.

Uganda has recorded 12 filovirus outbreaks over the 26-year period, including nine Ebola and three Marburg outbreaks, according to the research team. Among the four outbreaks examined closely were the 2017 Marburg outbreak in Kween and Kapchorwa, the cross-border Ebola outbreak in Kasese in 2019, the multi-district Sudan Ebola virus outbreak in 2022, and the 2025 outbreak whose index case was a health worker.
Strong systems after confirmation
Across the outbreaks reviewed, the synthesis found that Uganda has developed significant capacity to mobilise after laboratory confirmation. National and district task forces and technical response structures are activated quickly, supported by strong laboratory capacity, established coordination mechanisms and increasingly sophisticated surveillance systems.
The country has also built laboratory capacity around the Uganda Virus Research Institute, mobile laboratories, genomic sequencing, sample referral systems and the Results Dispatch System. Digital surveillance tools, Village Health Teams, survivor champions and established national and district coordination structures have further strengthened response capacity.
Detection remains a weak point
However, the findings point to a critical problem before confirmation: recognising a possible outbreak early enough.
For outbreaks originating within Uganda, the synthesis found that the period between a patient’s first presentation and confirmation ranged from nine to 27 days. This the study found is linked to low clinical suspicion and weaknesses in screening. Other recurring challenges included delayed access to emergency financing, infections among health workers, disruptions to essential health services, community mistrust and stigma, and limited follow-through on recommendations from previous After-Action Reviews.
Opening the workshop, the Dean, Prof. Rhoda Wanyenze, said understanding these delays requires going beyond identifying broad weaknesses to examining where response systems fail in practice.
“We can identify a broad challenge such as delayed detection from the literature, but your experience on the ground can help us understand the specific factors that create that challenge,” Prof. Wanyenze said while addressing district health officials from across the country.

“When we begin looking for solutions, we need to be able to target the actual problems rather than simply identifying broad challenges.”
The workshop brought together partners and colleagues from districts, including people directly involved in outbreak response, to validate the synthesis against frontline experience. Prof. Wanyenze noted that published literature, scientific papers and response reports cannot capture every operational reality, making practitioner experience essential to understanding where delays occur and what interventions have worked. Remarks validation workshop
Turning outbreak experience into continuous readiness
Among the priority actions proposed are stronger screening and alert systems for earlier detection; ring-fenced emergency financing and more reliable responder payment systems; routine infection prevention and control training; stronger occupational protection for health workers; continued investment in laboratories and genomic sequencing; and preparedness extending beyond districts traditionally considered outbreak hotspots. The study also recommends stronger community engagement and a formal mechanism to track and finance implementation of recommendations from After-Action Reviews.

Dr. Andrew Acero, Director of the EPiC project at FHI 360’s Uganda Office said the central challenge is ensuring that experience accumulated during successive outbreaks translates into lasting institutional capacity.
“The real value lies in ensuring that what we learn changes what we do. Our findings should inform policy, shape guidelines and training, strengthen systems and ultimately improve practice.”
He noted that preparedness cannot begin only after an emergency has been declared, but must be built through sustained relationships, systems and capacity before outbreaks occur. Remarks validation workshop
The EPiC project is led by FHI 360 with core partners including Right to Care, Palladium and Population Services International.
Health
Uganda’s HIV Treatment Gains Bring the Youth Gap into Focus
Published
3 days agoon
October 5, 2026
Uganda’s latest national HIV survey reveals lower viral suppression among adolescents and young adults living with HIV than among older adults, even as the country records substantial improvements in controlling the virus. The findings come from Uganda Population-Based HIV Impact Assessment (UPHIA 2025), a national household survey examining HIV prevalence and whether people living with the virus know their status, receive treatment, and achieve viral suppression.
Releasing the preliminary UPHIA 2025 findings at the Uganda Media Centre on 1 October 2026, Minister of Health Hon. Dr. Chris Baryomunsi called for earlier prevention and testing, particularly among adolescent girls and young women, alongside support for treatment adherence. “We must reach out to the young people, ensure that they have information, they test, take treatment, and adhere to the treatment guidance,” he urged.
Hon. Baryomunsi recalled how fear had discouraged testing during his university years: “I remember when we were at university, we went for testing at the university hospital. We sat there for three hours. Some of us left without even testing because it was scary.” Today, he explained, “even if you test HIV positive, you can be initiated on treatment, and you live normally like the rest of those who don’t have HIV.”

UPHIA 2025 was locally led under the Ministry of Health’s overall leadership, with Makerere University School of Public Health serving as the prime implementer, a role ICAP at Columbia University held in the previous two surveys. The Uganda Bureau of Statistics led sampling, while the Uganda Virus Research Institute and National Health Laboratory and Diagnostic Services led laboratory operations. Regional referral hospitals and local governments supported implementation, and the U.S. government provided US$10 million through PEPFAR, along with technical assistance from the U.S. CDC.
UPHIA collected data from July to September 2025 among people aged 15 and above, including those outside routine treatment services. Of 6,283 eligible households, 94.4% completed interviews. Researchers interviewed 13,801 people and tested 13,477 for HIV.
Testing followed Uganda’s national algorithm, with laboratory confirmation of positive samples, viral-load measurement, and checks for antiretroviral medicines to establish treatment use. Researchers weighted the estimates to account for the sampling design. Participants received counselling and results, and those who tested positive were referred for treatment.
Hon. Baryomunsi thanked participants and their families for welcoming survey staff and contributing their time, information and samples, without which the national evidence would not have been available.

National progress and the youth gap
The survey estimated HIV prevalence, which means the proportion of people living with HIV, at 5.9% among those aged 15 and above, corresponding to about 1.496 million people in this age group nationwide. Prevalence was 7.3% among women and 4.1% among men, ranging from 1.3% in Karamoja to 8% in the South Western region.
Among people aged 15 and above living with HIV, 86% had achieved viral suppression, meaning a low amount of HIV in the blood, measured in UPHIA as fewer than 1,000 copies per millilitre. Suppression stood at 69.3% among adolescents and young adults aged 15–24 living with HIV, compared with 89.9% among those aged 50 and above. These estimates cover people living with HIV regardless of whether they know their status or receive treatment.

HIV prevalence among people aged 15–24 was 1.5%, including 2% among young women and 1% among young men. Among young women, prevalence was 1.3% at ages 15–19 and 2.8% at ages 20–24. These differences support attention to earlier prevention and testing, although they do not establish when infections occurred.
The highest prevalence estimates occurred among middle-aged adults: 15.7% among women aged 40–44 and 11.7% among men aged 45–49. Lower suppression among young people therefore requires attention alongside the higher HIV prevalence among middle-aged adults. Comparing the same age group across both surveys, viral suppression among people aged 15–64 increased from 74.9% in 2020–21 to 86.1% in 2025, while HIV prevalence remained at 5.9%.

Diagnosis and the path to 2030
The treatment results identify diagnosis as the main national gap. Among people aged 15 and above living with HIV, 85.3% knew their status. Of those aware, 99.1% were receiving treatment; among those receiving treatment, 96.5% had achieved suppression.
The 95-95-95 targets aimed for 95% of people living with HIV to know their status, 95% of those diagnosed to receive treatment, and 95% of those receiving treatment to achieve viral suppression by 2025. Among people aged 15 and above, Uganda exceeded the treatment and suppression targets, while diagnosis remained below target. UNAIDS’s Global AIDS Strategy 2026–2031 retains these targets towards ending AIDS as a public health threat by 2030.
According to WHO, viral suppression protects health and helps prevent HIV transmission. Uncontrolled HIV weakens the immune system, increasing the risk of serious illness. With continued treatment as prescribed, sexual transmission risk is negligible when HIV remains suppressed but detectable, and zero when undetectable. The Uganda AIDS Commission estimated over 34,000 new HIV infections in 2025, underscoring the importance of early diagnosis, timely treatment, and sustained suppression alongside other prevention measures.

The demographic stakes are substantial. People aged 15–24 constituted 21.2% of Uganda’s population in the 2024 census. The country’s Fourth National Development Plan, covering 2025–2030, prioritises a healthy, knowledgeable, skilled and productive population and reducing HIV through primary health care. Protecting young people’s health, therefore, supports their participation in education, work, and national development; UPHIA helps identify where services need greater attention.
Turning evidence into action
The study’s conclusions identify three priorities: sustain treatment outcomes, find people unaware of their status, and improve suppression among younger people. Permanent Secretary Dr. Diana Atwine connected the findings to the Ministry’s planning.
“We do believe that these results are a true reflection of what is happening in our country as far as the HIV status is concerned, and we do believe that it will give us a very clear direction and the roadmap that we are going to take in the next five years to target and to get our targets achieved.”

Acting on these priorities requires funding for services and research. Hon. Baryomunsi outlined plans to target resources where needs are greatest, strengthen district services and align partner support with government priorities. Responding to journalists’ questions, he noted the government’s intention to increase domestic funding for the HIV response, including research.
“The HIV/AIDS response, including research and surveys such as this one, has largely been funded by partners in the past. The government of Uganda is committed to allocating more resources from our domestic budget to support the response and research,” he noted.
For the first time in the UPHIA series, the survey assessed selected noncommunicable disease indicators among people aged 15 and above: 15.5% had elevated blood pressure, 24.8% were overweight or obese, and 0.9% had raised random blood glucose. These screening findings align with the Ministry’s integration agenda and Hon. Baryomunsi’s call to bring HIV and chronic care services together to address people’s wider health needs.
Speaking at the release of the preliminary results, U.S. Embassy Chargé d’Affaires Mikael (Mika) Cleverley described UPHIA 2025 as the first Population-Based HIV Impact Assessment worldwide fully led and implemented by the country itself.

“The study was led by Ugandan scientists, Ugandan managers, Ugandan public servants, Ugandan field teams, from design to data collection to analysis. And this is what two decades of focused strategic U.S. foreign investments in the public health sector was meant to produce, is to reinforce Ugandan leadership and Ugandan-led efforts.”
At the survey launch on 29 May 2025, MakSPH Dean Prof. Rhoda Wanyenze highlighted the partnership’s contribution: “The partnership between Makerere University and CDC has not only helped build national capacity in surveillance and epidemiology, but has also strengthened our ability to lead high-quality, large-scale national surveys.”

The Dean added: “After two decades of joint work, we are proud that UPHIA is now a fully Ugandan-led effort. This is critical to the sustainability of the skills and knowledge generation to inform our local response.”
UPHIA 2025 shows how far Uganda’s HIV response has advanced and where gaps remain. As the country works towards ending AIDS as a public health threat by 2030, reaching young people with testing, treatment, and continued care will be essential to extending those gains.

Read the full UPHIA 2025 summary results here:
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