How did Bangladesh implement?
- Bangladesh outsourced many elements of CHW programming to leverage the knowledge, resources, and experience of its NGO partners. The government’s shift from provider of services to manager of services has allowed NGOs to take the lead in innovating, testing, and delivering care.
- With research and a data-driven approach as a foundation, Bangladesh has continually adapted its programs to meet changing needs.
Bangladesh’s government welcomed and leveraged partners, harnessing NGO expertise and experience to strengthen its own programming and to fill geographic and programmatic gaps it knew it did not have the resources or expertise to address. The resulting programs, both NGO- and government-led, are remarkable for their community engagement and data-driven approach. What’s most interesting about Bangladesh’s story is how the country developed, managed, and sustained such multi-partner programming and created synergies, which we will explore in this section.
Data-driven, iterative approach
The design, implementation, expansion, and modification of Bangladesh’s community health efforts, both government and NGO-supported, were informed by comprehensive data collection efforts.
- In the 1970s, the focus was on addressing high fertility rates through family planning, when research showed the fertility rate in Bangladesh was 50 percent above the world average.
- In the 1980s, prevention of and treatment for childhood illnesses (oral rehydration solution, expanded program on immunization) were added to the package of services when research showed that 63 percent of childhood deaths in Bangladesh were due to vaccine-preventable disease.
- In the 1990s, maternal health (skilled birth attendance, antenatal care, postnatal care) and communicable diseases (tuberculosis) were added to the mix when research showed that less than five percent of deliveries occurred in a health facility and the maternal mortality ratio was over 500 per 100,000 live births.1
- And finally, in the 1990s and 2000s, a broad package of essential health services was introduced when Bangladesh signed onto the Millennium Development Goals and the Sustainable Development Goals, based on global research supporting the benefits of universal health care.
TIMELINE TABLE (GOVERNMENT: 1960 - 2015)
||Major Milestones||CHW Cadre Changes||Policy and Context Changes|
|1960||Promotes use of family planning products via field and clinic
||HAs focus on malaria and smallpox vaccination||Rural health center scheme launched, with focus on building facilities at sub-district and union level to provide variety of MNCH services|
Launches National Family Planning Program
|FWA cadre launched (primarily education, counseling and distribution of FP methods)||Bangladesh independence
First five-year plan and population policy (73-80); focus on rural health care; DGFP created and focus on family planning
|1980 - 1984||Launches national Oral Rehydration Program
Launches initial EPI efforts
|HAs shift to provide child health services (EPI, ORS, and Vitamin A)
FWAs begin to promote immunization, ORS and breastfeeding
|Second five-year plan and population project (80-85); focus on family planning
National Drug Policy adopted; leading to growth of pharmacies across the country
|1985 - 1990||Launches National Control of Diarrhea Disease Program (CDD) which integrates gov’t and NGO ORS distribution
Launches national EPI program, integrating gov’t and NGO EPI
Establishes facilities for maternal health to complement CHW
|10K FWAs added to expand services into screening for complicated pregnancies, ORS and immunization for women
HAs cement focus on EPI
|Third five-year plan and population project (86-91); focus on EPI|
|1990 - 1994||Trains traditional birth attendants (TBA) and midwives to improve skilled birth attendance; largely fails
Launches National TB program (NTP) in collaboration with NGOs
|FWAs collaborate with TBAs to increase SBA
HAs continue to focus on EPI
|Fourth five-year plan and population project (92-97); focus on integrating maternal and child health care, family-planning, nutrition care, and health education|
|1995 - 2000||Pilots IMCI approach
Formal review of IMCI confirms feasibility
First launch of community clinics
|FWA and HA begin to provide services at the community clinic based on ESP policy designed through SWAp||First SWAp- HSPP (1998-2003, including ESP and CC|
|2000 - 2004||National IMCI strategy launched
Community clinics halted due to change in government
Maternal Voucher scheme introduced to increase use of facilities for delivery but largely unsuccessful
|Female HA/FWA trained to be Community Skilled Birth Attendants (CSBA)
HAs begin to provide IMCI services (mainly promotion)
|Second SWAp- HPNSP (03-10), with focus on skilled birth attendance
BNP takes over power
National Strategy for Maternal Health Launched
|2005 - 2010||Community clinics revitalized
National malaria and MNCH programs are launched in collaboration with NGOs
|Community health care provider (CHCP) cadre created (based at community clinic)||Awami League returns to power|
|2010 - 2015||Community clinics embedded into health sector planning
Community groups formalized to support community clinics
Focus on building health management information system that reaches down to community level
|CHCPs begin to receive SBA training
FWA, HA and CHCP formalize collaboration
|Third SWAp- HPNSDP (11-16), includes community clinics and prioritizes UHC and CC referrals and integration
UHC/ health finance strategy launched
TIMELINE TABLE (BRAC)
|Major Milestones||CHW Cadre Changes|
Begins with focus primarily on disaster relief following Bangladesh war of independence
|Launches first CHW pilot with male paramedics
Launches revised pilot with female CHWs; focus on family planning and health promotion
|1980 - 1984||Launches and begins to scale home-based ORS through program called OTEP (initiated in 1979 after some piloting with ICDDR, b in the 1970s)||Trains “ORS workers” as part of OTEP|
|1985 - 1990||Continues to scale home-based ORS
Partners with government in EPI program
Develops child survival and essential health care (EHC) programs that create the foundation for further investments in community health
|CHWs trained to provide EPI|
|1990 - 1994||Focus shifts to integrated development
Creation of women health development program
BRAC signs an MOU with the NTP to scale TB-DOTS across the country via CHWs
|Launches Shasthya Shebika community health volunteer cadre and begins to scale through the NTP and the EPI
Begin to use CHWs to detect and treat ARI
|1995 - 2000||Begins malaria control program
||TB program results in some increase in the number of BRAC CHWs|
|2000 - 2004||Global Fund supports BRAC TB scale
Partners with government on IMCI strategy
|TB program continues to increase the scale of the CHW program rapidly
Shasthya Shebika’s play important role in national IMCI strategy
|2005 - 2010||Partners with government on national malaria control and MNCH programs
Launches Manoshi (urban CHW program)
|Launches Shasthya Kormi cadre to supervise Shasthya Shebikas
Shasthya Kormis are able to provide a higher level of maternal health care services such as ANC and PNC
|2010 - 2015||Revitalization of Shasthya Shebika program||Addition of blood pressure screening, cancer screening and vision care
Reduction in size of Shasthya Shebika program to support larger service area and income generating opportunities
This data-driven approach is supported by four central pillars of program design shared by many of the CHW efforts included in this analysis:
- Problem-driven approach
- Culture of Research
- Piloting and scaling
- Channels for innovation diffusion
CHW interventions are a response to an existing problem, rather than a solution looking for a problem. As such, they are expected to change as needs change. This approach necessitates the continual monitoring of needs and a system responsive to this data.
Continuous monitoring helps identify gaps in programming and low-performing programs. This starts with CHWs in the field collecting research. But it also includes important surveillance sites such as the International Centre for Diarrheal Disease Research, Bangladesh’s (ICDDR, B) Matlab, just outside Dhaka, which have continually collected data on health trends and shared that data widely.
Matlab has also served as a testing ground for government and NGO pilots. The piloting of new approaches in such an environment provides data that can be used to inform improvements and generates evidence for advocacy.
Just as important as this research is connecting the research community to policy makers to ensure the dissemination of evidence. The National Institute for Population Research and Training (NIPORT), established by the Ministry of Health and Welfare (MOHFW) in 1977 serves as a key link in this respect. NIPORT is an autonomous research institute which conducts public health surveys (e.g., demographic health surveys, maternal mortality survey, health facilities surveys, etc.) and implementation science studies, and then disseminates learnings from these studies to a broad range of government and NGO stakeholders. The hope is that these leaders then use presented learnings to make changes to the existing program, or design new programs to address these gaps and challenges.
For example, data from the 2014 Demographic and Health Survey showed the total fertility rate was much higher in Sylhet and Chittagong than in other divisions. NIPORT shared this finding with the Directorate General of Family Planning through a series of national consultations. The ministry then advocated for additional NGO-contracted CHWs to work in these areas to provide information about and access to modern contraceptives.
NIPORT also ensures the information gained through research helps shape the country’s public health research agenda and is factored into the training of government health workers who provide family planning services, including FWAs.
Leveraging partner's resources
“We see our role as the coach - always on the sideline - looking at the data and then building awareness of the relevant parties about what the national survey results mean for them and what are the expectations of the government to use additional research and/or pilots to address the challenges identified in the national surveys.”- Government official2
Throughout the four distinct phases in the evolution of Bangladesh’s CHW effort - from a focus on family planning in the 1970s, to the addition of child health in the 1980s, then maternal health in the 1990s, to universal health care in 2010 - one constant has been the government’s reliance on NGO partnership to evaluate, innovate, adapt, expand, and improve programming to strengthen access to health care across Bangladesh.
Evidence of the government’s heavy reliance on partner resources (financial and human) and expertise can be observed, from the very beginning. When the government wanted to test different approaches for its family planning CHWs, it turned for assistance to the international health research institute based in Bangladesh, icddr,b. The research institute rigorously tested various approaches and recommended an evidence-based best practice which the government adopted.
In the 1970s, when the government’s clinic-based diarrhea treatment program to reduce child mortality had limited success, the government relied on an NGO to pilot a way forward. In this case, BRAC launched a CHW-supported program to teach mothers how to make and deliver ORS to their sick children at home without the support or involvement of highly-trained health workers. Again, the government adopted learnings from this program to inform the CHW-supported National Control of Diarrhea Disease Program in 1985, which, combined with BRAC’s work with ORS, helped Bangladesh reduce diarrhea mortality and under-five deaths.3
Oral rehydration solution (ORS) coverage
Later, in the early 1980s, the government contracted BRAC and CARE to train their own CHWs to mobilize support for immunization in regions where government CHWs were not yet firmly established. Immunization coverage rates (e.g., BCG, DTP3, measles) climbed from under five percent in 1985, to over seventy percent by 1995. By 2010, national immunization coverage had reached over ninety percent.3 This contributed to significant reductions in child mortality. Today, nearly 25 different NGOs support this program.
Community health worker density and immunization coverage
We can see the government relying on NGO CHWs again in the early 1990s, when it determined that less than five percent of deliveries occurred in a health facility and the maternal mortality ratio was over 500 deaths per 100,000 live births. The government responded by engaging UNFPA (United Nations Population Fund) to train over 50,000 traditional birth attendants (TBA) to perform safe deliveries and identify and refer complicated cases to midwives at sub-district hospitals as needed.4 When, in the 2000s, it was clear that this was not enough, the government contracted with UNICEF and BRAC to train more than 50,000 of their own CHWs, primarily in northern Bangladesh.5 Their mission was to improve antenatal care and skilled birth attendance rates by identifying pregnancies early, providing ANC services, and promoting skilled birth attendance.
ANC coverage increased from less than five percent in the early 1990s to more than 31 percent by 2014. Skilled birth attendance increased from 12 percent in 2000, to 46 percent in 2014.
Women receiving 4+ antenatal care visits and skilled birth attendance
“The number one reason why Bangladesh has developed successful community health efforts is because of the NGO and private sector’s focus on experimenting and innovating - this trial and error approach has been critical to the success of community health in Bangladesh.”- Bilateral development funder
NGO-GOVERNMENT PARTNERSHIP APPROACHES
In this way, Bangladesh developed a highly pluralistic CHW system. The government’s network of CHWs and facilities, while on paper seemed comprehensive, in practice contained gaps and, as a result, was responsible for less than 20 percent of the curative services offered.7
NGOs have helped the government deliver that 20 percent pie. In addition, NGOs have delivered their own services, often, but not always, to those not reached by government programs.
The pluralistic system, with multiple channels of supplementary, complementary, and overlapping programming has sometimes been messy, but it has been effective in introducing a large portion of Bangladesh’s population – especially women – to the national health system for the first time.
A broad range of NGO, private and informal providers play a critical role in Bangladesh’s health system. One recent study found that the public sector is responsible for less than 20 percent of curative services.7 To manage and coordinate all the complementary and supplemental programming, Bangladesh has instituted multiple levels of coordination across the CHW space:
- At the local level, NGOs and government officials attend a monthly working group called the Upazila (sub-district) Health Council.
- At the national level, the Sector-Wide Approach Health Nutrition Population Sector Program explicitly encourages the role of the private sector and NGOs in health care delivery, and more squarely put government in a policymaking and monitoring role. A range of national technical committees and working groups are part of the Sector-Wide Approach.
All of this leaves much room for NGOs to develop, scale, and innovate relatively unencumbered by government bureaucracies, often rife with barriers. It also leaves much room for duplicative programming. To learn how Bangladesh is addressing duplicative programming, click here.
Cultivating and sustaining political commitment
Political commitment is a nebulous concept. While it can be easily identified, deconstructing it to help inform policy and practice can be challenging.
In the case of Bangladesh, political commitment for CHW programming has been expressed in three key ways:
- The declaration of support from high-level and influential leaders, who often used media campaigns to communicate their support.
- Institutional commitment, both in the form of the inclusion of health care as a constitutional right, and prioritization of the CHW as a designated health care provider in policy documents.
- The allocation of resources for CHW programming in government budgets.
Generating political will is a process that requires excellent timing. The political system is more open to new ideas during major political reforms, new administrations, or when crises occur.
Bangladesh’s success demonstrates this dynamic. Supporters of CHW programming in Bangladesh elevated the urgency of health challenges that CHWs are particularly well-positioned to address – such as family planning and generating demand for immunization – during such policy windows. These periods included immediately after the country’s founding, during changes in government, and during health crises. They promoted CHWs as a powerful and flexible tool to address the health challenge of the moment.
The first minister of health, for example, upon launching the CHW program to address family planning, stated:
“An all-out preparation has been made in Bangladesh to make it [family planning] a complete success on war footing preparation… it is universally recognized that this is an essential pre-condition not only for the prosperity but for the survival of the nation.”- First minister of health8
BRAC, has also leveraged windows of opportunity to further support CHW programming. For example, during key national elections, BRAC together with the National TB programme, media, and stakeholders called on political parties to make specific pledges to increase CHW programming to reduce TB and incorporate these pledges into their platforms.9
The use of CHW programs to address crises and urgent health challenges further boosts support for them. The results and impact of high-profile campaigns can provide powerful evidence to evangelize the CHW approach and build a coalition of champions.
Integration with the wider health system
Bangladesh’s government CHWs were, from the very beginning, paid civil servants meant to function as the most basic level of a diverse, but unified health system. They conduct household visits to promote health education, mobilize demand for and deliver basic curative services, and provide referrals for more complicated care in higher-level facilities.
In the early days of the CHW programming, CHWs provided all of this care in patients’ homes or in community institutions such as mosques, schools, and even stores.
In 1998, the government constructed more than 13,000 community clinics to help reduce the outreach burden on government CHWs – ensuring CHWs spend less time traveling to patients and more time actually seeing patients. The clinics, a basic health facility that provides preventive, promotive and curative care, dispenses medicines, and provides referrals to upstream facilities, help ensure that only seriously ill patients, who need more sophisticated care, use the higher-level facilities. At the same time, by making essential health care more accessible, the clinics also serve to increase the number of seriously ill patients referred for care at higher-level facilities.
Today, eighty percent of the population is within a 30-minute walking distance of a community clinic.
Government program overview
Bangladesh understood that for its CHWs to make an impact they would need to engage with the community in management, oversight, and cost-sharing to gain support. The country’s 13,000 community clinics demonstrate one small way Bangladesh has secured community support and engagement.
Clinics are built on land donated by the community. Furthermore, in every community, groups comprised of local government representatives, CHWs, teachers in the local school, and residents, provide oversight of the community clinic’s activities and are tasked with mobilizing the community to use the clinic’s services. Critically, the Union Parishad member, an elected local government official of the community clinic’s catchment area, plays a leadership role in the community group. The participation of such a high-ranking local official helps influence community members to support and use clinic services.
Further, while costs incurred for construction, medicine, service providers, logistics, and other inputs are borne by the government, each community clinic also maintains a bank account and attempts to raise funds from community members to defray general operating costs.
This ongoing community-government partnership is intended to ensure that the community feels vested in - and has some influence over - the community clinic and services it offers.
- 1Mitra SN, Nawab Ali M, Islam S, Cross AR, Saha T. Bangladesh Demographic and Health Survey, 1993-1994. National Institute of Population Research and Training - NIPORT/Bangladesh, Mitra and Associates/Bangladesh, and Macro International. 1994.
- 2Last Mile Health interview (NIPORT).
- 3El Arifeen, S., Christou, A., Reichenbach, L., Osman, F. A., Azad, K., Islam, K. S., ... Peters, D. H. Community-based approaches and partnerships: Innovations in health-service delivery in Bangladesh. The Lancet. 2013; 382(9909):2012-26.
- 4Last Mile Health interview (UNFPA).
- 5In remote regions of Bangladesh, community health workers break barriers to health care. UNICEF. https://www.unicef.org/childsurvival/index_66012.html. Updated October 3, 2012. Accessed February 8, 2019.
- 6Last Mile Health Interview (MSI)
- 8Proceedings from national family planning consultation in Dhaka, 1972. World Bank. 1972.
- 9Experts demand electoral pledges on TB control in Bangladesh from political parties. Bdnews24.com. https://bdnews24.com/health/2018/12/11/experts-demand-electoral-pledges-on-tb-control-in-bangladesh-from-political-parties. Updated December 11, 2018. Accessed January 30, 2019.