Background: Village health worker (VHW) programs in Uganda have achieved limited success, due in part to a reliance on volunteerism and a lack of standardized incentive mechanisms. However, how to best incentivize VHWs remains unclear. Doctors for Global Health developed a performance-based incentives (PBI) system to pay its VHWs in Kisoro, Uganda, based on performance of tasks or achievement of targets. Objectives: 1. To describe the development of a PBI system used to compensate VHWs. 2. To report cost and health services delivery outcomes under a PBI system. 3. To provide qualitative analysis on the successes and challenges of PBI. Methods: Internal organization records from May 2016 to April 2017 were retrospectively reviewed. The results of descriptive and analytic statistics were reported. Qualitative analysis was performed by the authors. Findings: In one year, 42 VHWs performed 23,703 remunerable health actions, such as providing care of minor ailments and chronic disease. VHWs earned on average $237. The total cost to maintain the program was $29,844, or $0.72 per villager. There was 0% VHW attrition. Strengths of PBI included flexibility, accountability, higher VHW earnings, and improved monitoring and evaluation. Conclusions: PBI is a feasible and sustainable model of compensating VHWs. At a time where VHW programs are sorely needed to address limitations in healthcare resources, yet are facing challenges with workforce compensation, PBI may serve as a model for others in Uganda and around the world.

Background As the rate of COVID-19 infections grew in Kisoro, Uganda, fear and misinformation about the virus were rife. Accurate, trustworthy community education seemed essential to support prevention efforts in the villages, allay widespread fear of death, and avoid the overwhelming of Kisoro District Hospital (KDH). Since 2005, KDH has collaborated with an NGO, Doctors for Global Health (DGH) and the Albert Einstein College of Medicine, NY, USA, to sponsor a robust Village Health Worker (VHW) programme in 52 villages in the Kisoro district. Community health education has been a cornerstone of the programme since its inception, and VHW-delivered home talks with portable, pictorial flip charts have shown success as a model for health education. Here, we describe a COVID-19 home-talk programme developed in a short time in response the COVID-19 pandemic and evaluate learning from this programme compared with learning from local radio (the main channel of information) and other regional information sources. In a COVID-19 lockdown, would the home-visit model be applicable? Would a health-worker delivered home-talk programme add to learning otherwise garnered from radio, television or neighbours? Methods We developed a 30 min COVID-19 home talk in 10 days; we trained 48 VHWs in an intense 2-day training, then monitored and certified VHW's skills over three sessions of field observation. Home talks were then fully implemented with a maximum of four adults per talk and social distancing was observed. To measure the retained learning from home talks, one adult per talk answered a six-item pre-test, and 3-5 weeks later, we randomly selected 20% of these participants and invited them to complete an identical post-test. To control for media exposure and assess contamination of the talk messages over time in study villages, residents of non-participating villages also completed tests at the same time that study participants completed post-tests in participating villages.

The literature on the global burden of noncommunicable diseases (NCDs) contrasts a spiraling epidemic centered in low-income countries with low levels of awareness, risk factor control, infrastructure, personnel and funding. There are few data-based reports of broad and interconnected strategies to address these challenges where they hit hardest. Kisoro district in Southwest Uganda is rural, remote, over-populated and poor, the majority of its population working as subsistence farmers. This paper describes the 10-year experience of a tripartite collaboration between Kisoro District Hospital, a New York teaching hospital, and a US-based NGO delivering hypertension services to the district. Using data from patient and pharmacy registers and a random sample of charts reviewed manually, we describe both common and often-overlooked barriers to quality care (clinic overcrowding, drug stockouts, provider shortages, visit non-adherence, and uninformative medical records) and strategies adopted to address these barriers (locally-adapted treatment guidelines, patient-clinic-pharmacy cost sharing, appointment systems, workforce development, patient-provider continuity initiatives, and ongoing data monitoring). We find that: 1) although following CVD riskbased treatment guidelines could safely allocate scarce medications to the highest-risk patients first, national guidelines emphasizing treatment at blood pressures over 140/90 mmHg ignore the reality of "stockouts" and conflict with this goal; 2) often-overlooked barriers to quality care such as poor quality medical records, clinic disorganization and local employment practices are surmountable; 3) cost-sharing initiatives partially fill the gap during stockouts of government supplied medications, but still may be insufficient for the poorest patients; 4) frequent prolonged lapses in care may be the norm for most known hypertensives in rural SSA, and 5) ongoing data monitoring can identify local barriers to quality care and provide the impetus to ameliorate them. We anticipate that our 10-year experience adapting to the complex challenges of hypertension management and a