Incentives for mothers, health workers and "boda–boda" riders to improve community-based referral process and deliveries in the rural community: a case of Busoga Region in Uganda.

Background: This study set out to investigate how incentives for mothers, health workers and boda–boda riders can improve the community-based referral process and deliveries in the rural community of Busoga region in Uganda. Both the monetary and non-monetary incentives have been instrumental in the improvement of deliveries at health centres. Methods: The study was a 2 arm cluster non-randomized control trial study design; with intervention and control groups of mothers, health workers and boba–boda (commercial motor-cycle) riders from selected health centres and communities in Busoga region. Among the study interventions was the provision of incentives to mothers, health workers (midwives and VHTs) and boda–boda riders for a duration of 6 months. Monetary and non-monetary incentives were applied in this study, namely; provision of training, training allowances, refreshments during the training, payment of transport fares by mothers to boda–boda riders, free telephone calls through establishment of a pre-paid Closed Caller User Group (CUG) and provision of bonus airtime to all registered CUG participants and rewards to best performers. The study used a mixed methods design. Descriptive statistical analysis was computed using STATA version 14 for the quantitative data and thematic analysis for qualitative data. Results: Findings revealed that incentives improved community-based referrals and health facility deliveries in the rural community of Busoga. The proportion of mothers who delivered from health centres and used boda–boda transport were 70.5% in the intervention arm and only 51.2% in the control arm. Of the mothers who delivered from the health centres, majority (69.4%) were transported by trained boda–boda riders while only 30.6% were transported by un-trained boda–boda riders. And of the mothers transported by the boda boda riders, 21.3% in the intervention arm reported that the riders responded to their calls within 20 min, an improvement from 4.3% before the intervention. Mothers who were responded to between 21–30 min increased from 31.4% to 69.6% in the intervention arm while in the control arm, it only increased from 37.1% to a dismal 40.3%. Interestingly, as the time interval increased, the number of boda–boda riders who delayed to respond to mothers' calls reduced. In the intervention arm, only 6.2% of the mothers stated that boda–boda riders took as many as 31–60 min' time interval to respond to their calls in post intervention compared to a whopping 54.9% in the pre intervention time. There was little change in the control arm from 53.2% in the pre intervention to 41.2% in the post intervention. Conclusion: Incentives along the maternal health chain are key and the initiative of incentivising the categories of stakeholders (mothers, midwives, the VHTs and the boda–boda riders) has demonstrated that partnerships are very critical in achieving better maternal outcomes (health facility-based deliveries) as a result of proper referral processes. Plain English Summary: Maternal and child health has become a priority area of focus among health policy makers and planners. Several interventions are being tried in an effort to increase deliveries in health facilities in order to realise better health outcomes. This study focused on how incentives for mothers, health workers and boda–boda riders can improve the community-based referral process and deliveries in the rural community of Busoga region in Uganda. Two groups of boda–boda riders, mothers and health workers were followed up. One group was given incentives while the other was not. The incentives included training and training allowances, refreshments during training, payment of transport fares by mothers to boda–boda riders, free telephone calls and provision of bonus airtime to all registered CUG participants and rewards to best performers. The results of this study showed that incentives help to boost deliveries from health facilities hence improving maternal outcomes. In intervention group, 70.5% of mothers who deliveries from health facilities were transported by boda–boda riders whereas this was only 51.2% in the control group. The response time of boda–boda risers to calls for transport by expecting mothers improved tremendously in the intervention group when compared to the control group. All the targeted parties—boda–boda riders, mothers, midwives and Village Health Teams were more active and motivated to work towards improving maternal health of the mothers. [ABSTRACT FROM AUTHOR]