Social enterprise sexual health scheme doubles contraceptive use

A programme in Kibaale, a rural district in west Uganda, which established a network of micro-pharmacists to provide free sexual and reproductive health advice alongside purchasable products, doubled contraceptive use and improved knowledge of sexually transmitted infections (STIs), but did little to improve knowledge on HIV.

The Healthy Entrepreneurs programme, which began in Uganda in 2015, recruited members of village health teams to become ‘community health entrepreneurs’ (CHEs). Each CHE underwent a five-day training course that mainly focused on sexual and reproductive health and rights (SRHR), including issues relating to HIV prevention, transmission and treatment.

After training, each CHE invested 185,000 Ugandan shillings (UGX) (equivalent to US $50) for which they received US $100-worth of pharmaceutical supplies, such as antibiotics, contraceptives, sanitary pads, soap and vitamins, on credit. They also received a solar-chargeable tablet loaded with business management applications and videos on various aspects of SRHR. Each video used Ugandan actors and was available in English and local languages.

The entrepreneurs were then tasked with actively reaching out to other people in their communities to provide free health advice with a focus on SRHR. The advice they provided was based on their own knowledge, gained from the SRHR training, and the videos on their tablets. Alongside this, each CHE ran a micro-pharmacy selling essential medicines and health products.

The CHEs replenished stocks at a local warehouse each month where they also attended compulsory peer-meetings and refresher training. The entrepreneurs were encouraged to use part of their micro-pharmacy profits to pay back their loan.

To assess the programme’s impact, surveys were conducted in 2017 with around 1,210 adults of reproductive age (18 to 49 years for women and 18 to 54 years for men) from 25 villages in the areas. Around 60% of people lived in a village with a CHE who had been active for more than a year.

The proportion of people using at least one modern contraceptive method in areas with active CHEs was found to be more than twice as high than in areas without CHEs (21% compared to 10%). In addition, 90% of households in areas with CHEs had heard of at least one modern contraception method, compared to around 64% of households in unexposed areas.

People in all villages were fairly knowledgeable about STIs and their symptoms. Around half (53%) of people in villages without CHEs could name at least one STI, compared to 70% in villages where CHEs operated. The proportion of people who knew at least one symptom of an STI was slightly lower, standing at 43% in villages without CHEs and 61% in communities where CHEs were active.

However, people demonstrated much poorer knowledge on HIV, even in places with CHEs. Only a third (32%) of people in villages with CHEs – and a quarter (24%) in villages without CHEs – could correctly identify at least two ways to prevent HIV, knew that healthy-looking people can be HIV-positive, and rejected at least two local misconceptions about how HIV is transmitted.

The findings suggest social entrepreneurship schemes can strengthen the role of lay health workers in providing sexual and reproductive healthcare – although their role in helping to improve knowledge of HIV prevention and transmission needs further examination.