What did Bangladesh do?

A range of complementary programs and partners

Bangladesh’s government, its civil society partners, and even private sector actors created a patchwork of overlapping, supplementary, and complementary CHW programs that delivers a range healthcare, from health education and preventive care, to simple treatment for common illnesses. The programs grew and shifted in response to data on health challenges and the CHWs’ own performance.

Bangladesh is remarkable not only for the number of CHW cohorts, but also for the programs’ focus on women’s empowerment, sustainability, and community mobilization and engagement with regard to both the CHWs themselves and the clinics where many of them work. We will discuss each of these aspects in this section.

No NGO has more robust CHW programming than BRAC. In this section, we will compare BRAC’s CHWs with the government’s cohort.

Government, NGO, and private sector entities have each used CHWs to increase demand for and expand access to a wide range of critical health services across Bangladesh. While each cadre has its own training, management and supervisory mechanisms, package of services, and incentive system, there are similarities across programs.

Chief among them are:

Each of these cadres provides another window into understanding Bangladesh’s success in improving health outcomes through a patchwork of programs. And, as a whole, these cadres demonstrate both the rich diversity of approaches and the risk of duplication of efforts.

Indeed, the various NGO cadres have not, among themselves, coordinated the delivery of health services by geography, patient type, or service type. Nor have NGOs necessarily concentrated their efforts in areas underserved by the government.

BRAC CHWs

NGO CHWs outnumber the government’s CHWs by a wide margin (80,000 to 50,000). The largest cohort of NGO-supported CHWs is BRAC’s cadre, which has existed almost as long as the government’s program. Like the government’s program, BRAC’s CHW program evolved from a vertical approach – specifically a focus on access to family planning – to a broader range of basic preventive care.

BRAC’s CHWs are selected from BRAC’s village-level microfinance organizations. Studies have demonstrated that connecting microfinance programs with health education magnifies the impact of health education programming. ¹ This may be the case with BRAC CHWs, as they can reinforce their health messaging at regular microfinance group meetings. Further, the women attending microfinance meetings have, by virtue of their participation in microfinance groups, secured additional assets and enhanced their roles as decision-makers within their families. This role puts them in a stronger position to act on the health information provided by CHWs.

BRAC’s CHWs consist of two cadres:

The initial training and the quarterly one- to two day-long refresher courses both Shasthya Kormis and Shasthya Shebikas attend are participatory, interactive, and highly contextualized. During the monthly refresher courses, for example, participants discuss real cases, and model best practices and treatments.³ BRAC maintains both an independent control group that is responsible for managing the supply chain and an internal monitoring department. With the ultimate goal of improving quality, the department analyzes performance data to identify and address challenges and measure inputs and outputs, and quarterly performance.

SPOTLIGHT ON MONITORING AND EVALUATION - BRAC DATA MANAGEMENT

Government CHWs

The government has three cohorts of CHWs that reflect the organic development of its approach toward its bifurcated health system. They are:

Family Welfare Assistants work for the Directorate General of Family Planning and focus primarily on family planning, whereas Health Assistants and Community Health Care Providers work for the Directorate General of Health Services and have a broader focus. All three are selected, trained, and managed by their respective Ministry of Health and Family Welfare directorates. The community plays no role in the recruitment and selection of these government health workers. However, community groups do help manage and encourage the use of community clinics, where each of these three cohorts work. Click here, for information on how community groups help manage the clinics.

Private sector

Lastly, the private sector also uses CHWs to deliver health care services. These private sector efforts are largely separate from government and/or NGO efforts. They carry the potential for considerable duplication and inefficiencies because private sector CHWs, unlike NGOs, do not participate in local health sector coordination mechanisms such as the monthly upazila health committee meetings. For more information on how the government coordinates these CHW initiatives, click here.

The most well-known private sector CHW program may be that of the Social Marketing Company. This large effort is a spin-off from a project previously managed by the international NGO Population Services International. The Social Marketing Company selects rural women as community entrepreneurs. It provides them and local pharmacy agents with basic training on public health issues, along with instructions on how to appropriately and effectively dispense and communicate to patients the proper administration of basic public health products and drugs. The 10,000 women serving as CHWs in this effort and local pharmacy agents make a small profit by obtaining products, such as contraceptives and zinc syrup, at wholesale, and selling at retail.

Regular house calls

From the earliest CHW efforts in family planning, government and NGO programming has consistently incorporated house visits. This is not just a straightforward way of literally meeting patients where they are, but also serves as a powerful mechanism for monitoring community needs.

During house calls, government CHWs take a household inventory of basic demographic information including risk factors, health, and living conditions, and track all services delivered to the household. This data is shared with supervisors and used for planning purposes. This feedback loop enables programs to adapt to changing needs and ensures that local cultural and financial realities are considered as part of program design.

BRAC also incorporated regular household visitation, information collection, and surveillance into their programming. Shasthya Shebikas are expected to visit 10-30 homes per day. The Shasthya Shebika shares all data she collects in each household with her manager, who tracks it in a registrar. This ensures the Shasthya Kormis have a good sense of the needs and service use of each client.

It is important to note that data collected by these government CHW cadres have, until recently, not been shared. For information about how data supports program design and innovation, click here. For information about how the government is working to strengthen and standardize data collection, click here.

Community mobilization

At the outset, Bangladesh realized its health challenges did not reflect a simple supply-side problem. There was also little demand for health care in poor, remote, and culturally conservative rural villages accustomed to living without it.

CHWs have been expected to spur demand. They have leveraged their local knowledge and contacts with local leaders and civic groups to build interest in and support for important health campaigns and interventions.

CHWs efficiently mobilize communities to increase service uptake and support health campaigns through grassroots marketing efforts and user-centered design. This is illustrated by Bangladesh's approach to immunization. 

In 1985, despite attempts to improve immunization rates, Bangladesh’s BCG (tuberculosis), MCV1 (measles), Pol3 (polio), TT2+ (tetanus) immunization rates were the lowest in South Asia.⁵ That same year, the government launched an ambitious immunization program. But this time, it partnered with BRAC and CARE, whose CHWs mobilized community members to participate in the immunization campaign.⁴

The mobilization, which involved going door-to-door to educate parents about the importance of immunization, was so effective that the program reached 90 percent (24 million) of children in the country in a single day.⁶ Immunization coverage rates climbed from under five percent in 1985 to over seventy percent in 1995. A 2000 study conducted by CORE group inferred that higher immunization rates in some divisions were correlated with the use of CHWs and mass communication tools.⁷ By 2010, immunization coverage had reached over ninety percent.

Likewise, to increase the use of oral rehydration solution (ORS) in rural areas, BRAC trained CHWs to teach mothers how to prepare ORS at home. Research found that women would be more willing to use ORS if they could make it at home, rather than having to travel to a health facility with their sick child. BRAC believed that framing ORS as a household issue, rather than a medical one, would increase use. BRAC and icddr,b worked together on a series of pilots before working in collaboration with the government to distribute the product.⁸ During scale-up, BRAC researched reasons for low adoption and found that CHWs, having no experience with ORS and little understanding of why diarrhea was so dangerous to children, did not understand how or believe that ORS worked. BRAC brought them from the field to research labs in Dhaka to show how ORS worked. These CHWs were then advised to explain the science to community members, and to sip the ORS themselves during household training sessions, to convince mothers that the solution was healthy and would not harm their children.

This refinement of messaging and intensive focus on mobilization helped increase the rate of ORS treatment to more than 50 percent by the early 1990s.⁹

Community clinics staffed by CHWs

The year 1998 marked a milestone for Bangladesh’s efforts to improve health care. It was the year the country established a standard package of essential services and a “one-stop” health care model. Its center point was the community clinic – where the standard package of services would be provided by CHWs.¹⁰

This investment in a national network of brick-and-mortar clinics, alongside CHW programming, is in line with the emerging global consensus:¹¹ that investments in community-level facilities and community health workers complement one another. As CHWs seed demand for health care, the clinics improve CHWs’ ability to meet that growing demand by reducing the need for travel to patients’ homes, and increasing time available for treatment.

Moreover, the clinics serve as a pivotal gateway in two ways: they increase demand and referrals for more complicated care, ensuring patients who require complex care receive it, and they reduce the number of patients seeking care at higher-level facilities who could be just as well-served at lower-level ones. By screening patients, local health clinics rationalize the utilization of higher-level facilities for more serious health issues.^12 13

While a change in government leadership mothballed clinics for nearly a decade, the political winds shifted again in 2008, allowing clinics to reopen. By 2016, more than 13,000 community clinics were operational and staffed by all three cadres of government CHWs.

Each community clinic serves a population of 7,000 to 10,000 people. The clinic – usually a simple, two-room building – is a tangible demonstration of a community’s commitment to health care.

Community engagement with clinics starts from the very beginning. The clinics are constructed on land donated by the community. While costs incurred for construction, medicines, service providers, logistics, and other inputs are borne by the government, each community is asked to raise funds to defray general operating costs.¹⁴ The clinics are also managed by local community groups (for more information about community engagement, click here). It is notable that the government uses clinics to provide communities with more than just health care - the clinics give communities a voice in the health care they receive.

Today, 80 percent of Bangladesh’s population is within a 30-minute walk of a community clinic, marking a significant step toward access to care.¹⁵ The clinics provide basic medicine, first aid, MNCH services, IMCI, family planning education and services, immunization. They treat acute respiratory infections and diarrhea, provide nutritional education and micronutrient supplements, and screen for non-communicable diseases (such as diabetes). Finally, they refer complex cases to higher-level facilities, when necessary.¹⁵ Approximately 30 percent of community clinics also have Community-Based Skilled Birth Attendants (Family Welfare Assistants or female Health Assistants and female Community Health Care Providers with special training) who perform uncomplicated deliveries at the clinic itself.

While initial utilization of the clinics was low, by 2016, over 100 million people had used the clinics with one million of those patients being referred to higher-level facilities.

The availability of community clinics and the presence of community-based skilled birth attendants contributed to significantly increase both the percentage of women giving birth in a health facility (rising from 23 percent to 47 percent) and the percentage of births attended by a medically trained provider (rising from 34 percent to 49.8 percent) between 2010 and 2016.

Today, community clinics are the government’s flagship health program. They are monitored and evaluated through the fourth Sector-Wide Approach Health, Nutrition, and Population Sector Program (HNPSP) 2016-2022, and financed with government, pooled and non-pooled donor funds, and community support.¹⁶

Women’s empowerment

To appreciate why women’s empowerment became a critical part of many of the CHW programs in Bangladesh, it is helpful to consider the position of women in rural areas shortly after independence.

Upon gaining independence in 1972, Bangladesh faced a crisis. Bangladeshi women were having, on average, seven children.¹⁷ Other than that of Afghanistan, this was - at the time - the highest fertility rate in South Asia¹⁷ and 50 percent higher than the global average of 4.67 children.¹⁷ During this period, the country simply could not provide basic services for its citizens. Reducing fertility was a mechanism for both improving child health and reducing maternal deaths.¹⁸ Founding Prime Minister Bango Bandh Sheikh Mujibur Rahman called the high fertility rate the “number one challenge for Bangladesh” and made increasing access to family planning services a national development priority.⁸

The challenge was complicated. Only about five percent of Bangladeshi women had access to contraceptives. And the country was deeply conservative. Purdah, the seclusion of women in their homes by religious edict, prevented women from accessing basic health care, including effective contraception.¹⁹ Even those women whose families and communities allowed them to leave their home would be hard-pressed to find quality care. The country had among the lowest level of human resources for health in the world. In 1970, Bangladesh’s density of doctors was about half that of neighboring Pakistan and India.²⁰ Even today, the World Health Organization estimates that Bangladesh has only seven skilled health professionals per 10,000 citizens. That is roughly one third the minimum recommendation.²¹

The government and many NGOs, including BRAC, responded by developing CHW programming with three key goals: to improve the standing of women by shifting sociocultural norms in extremely conservative rural areas, to provide economic opportunities for women, and to improve women’s health.

The focus on women’s empowerment may be strongest and most apparent in BRAC’s approach.²² Key to their strategy was the exclusive reliance on women to serve as CHWs and deliver primary health care for women and children. CHWs are empowered through the engagement in community activities, building their skills and capacity for decision-making, and providing them with income-generating activities. BRAC positions CHWs as agents of change, empowering women and the community.

Hiring women as CHWs has three important impacts: it elevates the status of the women serving as CHW, it broadly improves the status of women within the community as a whole, and it increases access to health information and health care for women.

Elevating the status of women serving as CHWs

First, CHWs play an important and highly visible role in the community. They must meet with government officials and local authorities. Indeed, interviews with women CHWs reveal that many initially turned down the position because they did not feel ready for the responsibility and senior role within their community. A 1992 study of the Bangladesh National Family Planning Program found that by providing employment opportunities for women, in an environment where professional employment opportunities for women were scarce, the program improved the status of the women health workers.²³

Elevating the status of women broadly

Second, hiring women as CHWs shifts social norms by placing women in leadership positions within the community. The same 1992 study found that by providing employment opportunities for women, in an environment where professional employment opportunities for women were scarce, the program broadly made social boundaries less rigid for other women in the community.²³ Research shows female CHWs improve social acceptance of the mobility and work of young women.²⁴

Reaching women with health information and health care

Lastly, our key informants reported that women serving as CHWs are more effective at negotiating the delivery of health services and information to other women in culturally conservative settings.

Developing a sustainable model

BRAC’s CHW programing is based on an innovative entrepreneurship model designed to maximize sustainability by providing income to the organization and the Shasthya Shebikas, while delivering free or low-cost care to the rural poor. The key components of BRAC's sustainability approach are: limited initial investment and limited recurrent costs (e.g., commodities, training, mobilization), entrepreneurship development through in-kind seed fund, and the compensation provided to the Shasthyka Shebika (markup from selling goods, mobilization fee for each service provided, and performance based incentives).

The cycle starts with BRAC selling commodities, many of them made by BRAC community groups, to the Shasthya Shebika at a small mark-up. The Shasthya Shebika, who does not receive a salary, then sells these products, after another small mark-up, to the families she serves. She then pockets the mark-up. Finally, BRAC charges community members, on a sliding scale, a small fee for some of the health services the Shasthya Shebika delivers. BRAC uses these fees to keep the program going.

The sustainability of the program is dependent not only on these small mark-ups, as products make their way to patients, but also on achieving low turnover and high-performing Shasthya Shebikas.² It costs nearly $90 to train a Shasthya Shebika. Reducing the number of Shasthya Shebikas who need to be trained each year is critical to the program’s sustainability. Currently, the annual dropout among Shasthya Kormis is 5-10%, and among Shasthya Shebikas is 10-15%, which hinders sustainability.²⁵

BRAC is working to address this. To offset opportunity costs and ensure each Shasthya Shebika is motivated and able to establish a robust service, she is initially given a fixed revolving fund for buying essential medicine and health commodities from BRAC at cost price. She is also eligible for a second loan from her village BRAC microfinance group. Given that the income earned by a Shasthya Shebika depends primarily on her experience, competition (remoteness from local health infrastructure and other providers), interpersonal communication skills and reputation and community acceptability,²⁶ BRAC recently significantly reduced the number of CHWs (from 80,000 to 50,000). This reduces competition between CHWs and allows each CHW to serve a larger area with more families, thereby increasing her potential income.

For the majority of Shasthya Shebikas, even the meager income they receive through this work is a large motivator for their service.²

Engagement with community institutions

In addition to house calls, government and NGO CHWs work out of a wide variety of community institutions, from mosques and schools, to local businesses. In these spaces, CHWs may educate the public about the importance and availability of health care in the community, through posted signs or occasional in-person lectures. By using these public spaces to deliver their public health messages, the CHWs both gain the passive endorsement of those institutions and reach patients where they are.

This third-party endorsement has helped position the CHWs as a community pillar providing important services.

Perhaps the best example of this is BRAC’s use of its microfinance groups to recruit its CHWs, who then use microfinance groups to disseminate health messages.

BRAC CADRES

GOVERNMENT CADRES

COMPLETE GOVERNMENT AND BRAC ESSENTIAL HEALTH SERVICE PACKAGE