- Bangladesh’s pluralistic system initially provided more robust and innovative care than the government alone could muster. But now, 40 years on, it is increasingly viewed as inefficient.
- Lack of standards can allow for poor quality of care.
- Inequity in access to health care remains.
Bangladesh’s community health efforts have been impressive in their scope and ability to extend coverage of essential health services to poor rural populations. Of course, there have also been significant implementation challenges related to governance, human resources, and financing. The government of Bangladesh and NGOs are working to address these and other challenges, as detailed below:
Fragmentation and duplication of efforts
Bangladesh’s more laissez-faire policy environment and large NGO sector helped NGOs innovate and establish partnerships at scale. But it has also led to both fragmentation and significant inefficiencies. Perhaps the best example of this is the multiple CHW cadres, with overlapping service areas and baskets of services.
Realistically, this challenge can only be fully resolved by something Bangladesh has avoided over all these years: a unified national CHW strategy.
Ironically, the government has turned, once again, to NGOs for assistance in developing this strategy to better manage NGOs, harmonize CHW job descriptions, and strengthening standards in training, definitions, and care.1 Save the Children, USAID, and UNICEF are leading this work, which began in 2016.2
“Pluralism has been helpful, but we have now come to a point where we need more streamlined and high-performing services.”- BRAC official
The Bangladesh Medical Association and the Ministry of Health and Family Welfare, DGHS, and DGFP have formed a committee to recommend how to align roles and responsibilities.
It is important to note that fragmentation and varying skill levels and services of each CHW cadre also impacts patient care. CHWs’ training, function, and ability vary widely depending upon the organization they work for. So, if a BRAC CHW is not available, it is not always an equal value for a patient to seek out the next available CHW, who perhaps offers entirely different services and provides a different level of care. This uncertainty can lead to inconsistent and poor care, and undermine confidence in CHWs as a whole.
Inconsistent and incompatible data collection
The two Directorates who lead CHW programing, the Directorate General of Family Planning and the Directorate General of Health, as well as each private sector partner and NGO, each collect different data, from different sources, on different schedules. They store and manage that data in unique ways, creating a patchwork of systems that stops short of providing the sort of clear and actionable information that policymakers need.
To address this, Bangladesh and its partners are working to establish a culture of routine and clear data collection standards. Toward this end, Bangladesh plans to develop a fully digital health system, meaning all patient information collected by government CHWs will be on a national database by 2021.3 Already, all community clinics have a functional laptop computer (and internet) in which staff enter routine health information data, such as the numbers of patients treated and summary statistics on maternal health, childhood illnesses, accidents, and nutrition, in a standard manner.4 Even CHWs at community clinics are beginning to use electronic records that pull from and feed into this national system. In addition, all facilities are now required to enter data into an online dashboard that monitors performance at all facility levels, including community clinics. At the end of the year, “local health bulletins” are created to report on progress and these are also used to recognize certain community clinics for exceptional performance.5
CHW Vacancies and Absenteeism
Government CHW programs suffer from high vacancies and absenteeism. Approximately 15 percent of government CHW positions are vacant at any given time, and anecdotal evidence suggests absenteeism rates are exceedingly high.6 Even with the use of female CHWs, which reduces turnover, retention is cited as a major problem for government and BRAC workers, especially in hard-to-reach areas.7
Turnover increases training costs, reduces quality of care, and strains the workload of the remaining CHWs.
To address this, the government is prioritizing improved recruitment and retention strategies. A revised human resource for health (HRH) plan under development will "ensure adequate number of personnel with appropriate skill mix, deployment with terms and conditions, retention, career progression, job satisfaction, etc.”5
Likewise, BRAC’s program struggles with dropout rates of 5-10% annually among Shasthya Kormis, and 10-15% annually among Shasthya Shebikas.8 This turnover significantly undermines the organization’s goal of sustainable programming. The organization has reduced the number of CHWs to reduce competition between CHWs and increase their earning potential.
Bureaucracy and Governance
The government’s CHW programming suffers from bureaucratic and slow decision-making. For example, establishing a new CHW post requires approval from six ministries and institutional entities, and can take as long as three years.9 Moreover, key components of CHW programming, like recruitment, retention, and management, fall under the purview of a variety of ministries.
At the same time, there are significant gaps in government oversight of NGO CHW programming. For example, there are currently no minimum standards or training guidelines for NGO CHW cadres. Save the Children, UNICEF, USAID and others are partnering with the government to develop those standards and guidelines.
A 2002 study found that the vast majority of government CHWs did not have the necessary skills to deliver the essential service package, and the majority of clinics lacked the appropriate equipment and drugs.10 Such deficiencies undermine confidence in the CHW cadres.
To strengthen accountability and supervision structures at the community level, the government has begun to provide all government CHWs with tablet computers. The tablets allow the supervisor to regularly communicate with CHWs, and approve and monitor progress on their workplan.5 The tablets come preloaded with e-learning toolkits, including videos demonstrating common scenarios and best practices for diagnosis and counseling. These courses, developed by the government, can be viewed offline to help support CHWs’ learning and improve professionalism.11 However, ensuring proper and consistent use of the tablets can be challenging, given the minimal education level of some CHW cadres.
In addition, community groups that help manage the clinic have been tasked with addressing performance issues. These community groups, however, cannot ensure timely delivery of medicines to their local clinic, nor can they arrange supplementary training for any staff whose skills are insufficient.
Most health care in rural Bangladesh is provided by personnel known as “village doctors.” A 2007 study found that only four percent of these “doctors” had any government training.12 Another 2007 study of village doctors in Chakaria found that many of them engage in inappropriate and harmful practices.13 Why do sick people consult them if they do harm? Often, it is a question of availability and cost. At the time of the study, for example, Chakaria had only 39 formally trained doctors instead of the 250 necessary to adequately serve the administrative region’s population of half a million. Where formal medical doctors are not available, village doctors thrive. Further, many village doctors provide their care on credit.12
Health inequities across wealth quintiles and across geographies remain and are particularly large when it comes to rates of institutional delivery and immunization rates. Inequity in rates for under-five mortality across wealth quintiles has been falling. However, inequity between rural and urban areas for under-five mortality remain. The under-five mortality rate in urban areas is twenty-four percent less than in rural areas, and the infant mortality rate is two times higher in the lowest income quintile than it is in the highest income quintiles.14
Under-five mortality rate and health indicators by wealth quintile
Reduced donor support
Overall international donor support to the health sector (not limited to the Sector-Wide Approach) has been steadily decreasing as a share of the Ministry of Health and Family Welfare (MOHFW) budget. From a peak of over 40 percent of the budget in 2001, international donor support had fallen to about half that share by 2015.15
Save the Children. ICHW Project Document.
ICHW (Improving Community Health Workers Program Performances through Harmonization & Community Engagement to Sustain Effective Coverage at Scale). Save the Children. https://bangladesh.savethechildren.net/sites/bangladesh.savethechildren.net/files/library/ICHW.pdf. Accessed January 30, 2019.
Health, Nutrition, and Population Sector Program (HNPSP) 2016-2021. Ministry of Health and Family Welfare. Government of the People’s Republic of Bangladesh.
Birdsall K. A Quiet Revolution: Strengthening the Routine Health Information System in Bangladesh. Federal Ministry for Economic Cooperation and Development of Germany. 2014. https://www.mn.uio.no/ifi/english/research/networks/hisp/research-library/publications/his_bangladesh_long_en.pdf. Accessed January 30, 2019.
Health Bulletin 2017. Ministry of Health and Family Welfare. Government of the People’s Republic of Bangladesh. 2017. http://www.dghs.gov.bd/images/docs/Publicaations/HealthBulletin2017Final13_01_2018.pdf. Accessed January 30, 2019.
Health Bulletin 2017. Ministry of Health and Family Welfare. Government of the People’s Republic of Bangladesh. 2017. http://www.dghs.gov.bd/index.php/en/publications/health-bulletin/dghs-health-bulletin. Accessed January 30, 2019.
Last Mile Health Interview (Khaleda).
Quayyum T. Retention of Community Health Workers for an Intensive Community Level Maternal and New Born Care Programme in Rural Bangladesh. BRAC. 2015.
El-Saharty S, Powers Sparkes S, Barroy H, Zunaid Ahsan K, Ahmed SM. The Path to Universal Health Care in Bangladesh: Bridging the Gap of Human Resources for Health. World Bank. 2015. http://documents.worldbank.org/curated/en/686591467986284082/pdf/96623-PUB-9781464805363-P152375-PUBLIC-Box391441B.pdf.
Normand C, Iftekar MH, Rahman SA. Assessment of the community clinics: effects on service delivery, quality, and utilization of services. Health Systems Development Programme. https://assets.publishing.service.gov.uk/media/57a08c35ed915d3cfd001236/bang_comm_clinics_web_version.pdf.
Bangladesh Knowledge Management Initiative. Knowledge for Health. https://www.k4health.org/projects/bangladesh. Accessed January 30, 2019.
Mahmood SS, Iqbal M, Hanifi SM, Wahed T, Bhuiya A. Are 'Village Doctors' in Bangladesh a curse or a blessing?. BMC Int Health Hum Rights. 2010;10:18. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2910021/. Accessed January 30, 2019.
Bhuiya A, (Ed) Health for the rural masses: Insights from Chakaria. icddr,b. 2009. https://assets.publishing.service.gov.uk/media/57a08b63ed915d622c000c65/FHSbookHealthforRuralMasses.pdf.
Bangladesh Demographic and Health Survey 2014. National Institute of Population Research and Training - NIPORT/Bangladesh, Mitra and Associates, and ICF International. Dhaka, Bangladesh: NIPORT, Mitra and Associates, and ICF International. 1994.
Vargas, V, & Begum, T, Ahmed, S & Smith, O. Fiscal Space for Health in Bangladesh. The World Bank. 2016. http://documents.worldbank.org/curated/en/268141537541184327/Fiscal-space-for-health-in-Bangladesh-towards-universal-health-coverage.