In many parts of Sub-Saharan Africa, access to life-saving vaccines is not limited by supply but by the invisible gaps within health systems. Behind every successful immunization campaign stands a dedicated health worker often underpaid, under-recognized, or unpaid altogether. But what happens when innovation meets these gaps? When technology doesn’t just deliver convenience, but builds accountability, trust, and efficiency into healthcare delivery?
As part of a pioneering collaboration between Makerere University School of Public Health and the University of Dakar, Dr. Aweko from Makerere University coordinated the digital payments project. The principal objective of this project was to evaluate the impact of digital payment systems on health care delivery and to propose solutions for improving digital health payments to health workers involved in health campaigns across Sub-Saharan Africa and beyond.
Dr. Aweko reflects on what this project means for the future of primary health care in Africa and why the time to invest in digital health innovations for lasting impact is now.
Qn. Dr. Aweko, thank you for joining us. Could you start by giving us an overview of the research project you’ve been working on?
A. Thank you. The research I’ve been involved in is part of the Digital Health Payment Initiative and Research (DHPI-R), a three-year project implemented across 12 Sub-Saharan African countries. It’s led by Makerere University School of Public Health (MUSPH) in Uganda and Cheikh Anta Diop University in Dakar, Senegal, with financial support from the Bill and Melinda Gates Foundation and technical backing from the WHO and various ministries of health.
Qn. That’s impressive. How did this project come about?
A. The DHPI-R project grew from the Polio End Game Strategy championed by WHO-Afro and partners in 28 African countries. Digital payments were introduced as a key strategy to ensure timely and complete payments to campaign workers in immunization campaigns. While WHO and ministries implemented the payments, our team at Makerere University researched how well this digital payment strategy works in Uganda its effect on health worker motivation, campaign quality, and success.
Qn. What were some of the key findings from this research?
A. We found that digital payments are a worthwhile solution to the challenges of handling cash—especially in hard-to-reach areas. Across similar settings in Africa, over 2 million health workers involved in immunization campaigns have been paid digitally, with evidence showing improved motivation and better campaign quality.
Our research, which is grounded in a robust theory of change, examined not only efficiency and cost-effectiveness, but also security, transparency, and accountability. We looked at how these factors affect health worker performance, financial situations, equity, and retention.
Qn. What about challenges? Were there any concerns identified?
A. Certainly. While digital payments reduce many cash-related problems, they come with their own issues. Payment delays often averaging around 41 days frustrate workers. There are also high transaction costs, limited mobile money infrastructure in rural areas, and concerns about data security. Gender dynamics also matter; women can be empowered by digital payments but may face challenges if they don’t fully control the mobile devices used.
Qn. Can you share some of the project’s key activities and achievements?
A. Absolutely. We Co-created a research agenda addressing key knowledge gaps, some answered and others ongoing. We conducted a comprehensive landscape analysis of digital payments in Sub-Saharan Africa. We built capacity among implementers and researchers and established a community of practice with regular knowledge-sharing.
We also completed 18 sub-studies including a randomized control trial. We held frequent meetings and webinars to engage stakeholders. We also created two regional hubs: an Anglophone hub at MUSPH led by Prof. Peter Waiswa, and a Francophone hub at Cheikh Anta Diop University led by Prof. Adama Faye.
And we engaged with regional partners like WHO, Global Fund, and the Better than Cash Alliance, plus national ministries.
Qn. That’s a comprehensive approach. What policy recommendations do you make based on your findings?
A. We recommend strong leadership and early planning for campaign payments, investment in rural digital infrastructure, hybrid payment systems during transition periods, improved digital literacy and communication, and reduction of transaction costs. Also, integrating digital payment systems with national financial infrastructure under guidance from ministries of finance and health is critical.
Qn. Many projects start with good intentions but struggle with sustainability after funding ends. What is the sustainability plan for this digital payment initiative?
A. That’s a critical question. To ensure sustainability, we have taken several steps. Most importantly, the Digital Payments Centre was established at Makerere University School of Public Health to serve as a permanent hub for research, capacity building, and stakeholder engagement around digital payments in health. This centre supports ongoing innovation, policy engagement, and training beyond the initial project timeline.
Furthermore, the strong regional networks and communities of practice we built will continue to facilitate collaboration and knowledge exchange. We are working closely with ministries of health and finance to integrate digital payment systems into national health financing frameworks. Sustainability depends on embedding these solutions within existing government systems and investing in infrastructure and human capacity.
Qn. What’s next for this area of research?
A. There are 10 key research gaps we identified. These include assessing long-term sustainability of digital payment systems, cost-effectiveness comparisons with cash, optimizing data security, exploring equity and gender impacts, and understanding how digital payments might reduce corruption in health campaigns.
Qn. What message do you have for funders and others interested in supporting work in digital health payments?
A. I would say your investment is critical to transforming health service delivery, especially in rural and hard-to-reach areas. Digital payments not only improve transparency and accountability but also boost health worker motivation and campaign success.
However, it’s important to view digital payment systems as long-term investments requiring continuous innovation, infrastructure development, and capacity building. Support for ongoing research, policy advocacy, and integration with broader health financing systems will ensure the impact lasts beyond project cycles.
Campaign workers need assurance that they will be paid on time, this reliability drives success in health campaigns. Investing in solutions that guarantee this is investing in stronger, more equitable health systems.
Qn. Finally, any closing thoughts?
A. Campaign workers need assurance that they will be paid on time. The way they are paid is important, but timeliness is paramount. Digital payments offer a reliable and innovative solution to long-standing cash challenges, but more research and innovation are needed to optimize and scale these systems sustainably.