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
Authors: Muluya Kharim Mwebaza , Mugisha John Francis , Kithuka Peter , Kibaara Kenneth Rucha , Muwanguzi David Gangu , Ochieng Otieno George , Yitambe Andre , Wananda Irene 
Published: January 2022

Abstract
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.