Key Points

  • More than 130,000 CHW, most of them women, have been trained to provide a growing basket of critical services – shifting the status of women in rural Bangladesh and connecting them with the formal health system for the first time.
  • CHW programming has mobilized communities to demand, support, and utilize CHWs. 
  • A total 13,000 community clinics across the country have helped institutionalize CHW programming and connected communities with the formal health system.  

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:

  • an emphasis on empowering and serving women
  • the use of data to drive decision-making
  • the development of innovative and adaptable programming
  • a reliance on partners

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.

Ratio of community health workers to population in Bangladesh

Data Source: El Arifeen, S. 2013; Government of Bangladesh; BRAC; Phillips, et al, 1994. 

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:

  • Shasthya Shebika

    Shasthya Shebikas evolved from BRAC’s use of CHWs for ORS, family planning, and immunization campaigns in the 1970s. Launched in 1990, these volunteers, recruited from BRAC’s microfinance village organizations, are village women who receive three weeks of training and spend two to four hours a day, six days a week, visiting 10 to 30 families per day. They focus on disseminating health, nutrition, and family planning information, as well as motivating families to install tube-wells and improved latrines to improve hygiene. Their key demographic consumer is pregnant women. Shasthya Shebikas work to identify pregnant women in their community, explain the importance of antenatal care (ANC), and refer women to the more highly skilled Shasthya Kormis for ANC. They also educate pregnant women and mothers on the importance of Vitamin A supplementation, immunization, and birth control. Shasthya Shebikas also serve as low-level health providers, selling at a small markup, medicine for common ailments such as diarrhea and pneumonia, as well as vitamins, condoms, and safe delivery kits.

    Shasthya Shebikas receive a commission based on their sales. There are also performance-based incentives for identifying pregnant women and signing them up for antenatal care, ensuring adherence to directly observed therapy (DOTS) for tuberculosis, and referring individuals to health facilities.

    For their two to four hours of work each day, Shasthya Shebikas make a mean monthly income of about $25 per month or $300 per year. This income, though minimal, serves to reduce turnover. A 2011 study found that nearly 90 percent self-reported they became a Shasthya Shebika to earn an income.2

    Initially, Shasthya Shebikas were supervised by BRAC’s program organizers. But as the number of Shasthya Shebikas grew, two challenges arose: supervising them became a burden, and the Shasthya Shebikas had increased demand for care beyond their own bandwidth and abilities. To address those challenges, BRAC launched the Shasthya Kormis.

  • Shasthya Kormis

    While Shasthya Shebikas often focus on generating demand for care, Shasthya Kormis, launched in 2005, work to deliver that care. Shasthya Kormis are village women with a minimum 10 years of schooling who receive three to four weeks of medical training. The cadre, which now numbers 4,000, provides maternal health services (ANC/PNC), assists with deliveries, provides special care to low birthweight babies, manages cases of diarrhea, acute respiratory infections, and other illnesses in children under five, oversees TB treatment, and facilitates health promotion.

    Shasthya Kormis earn $50 a month from BRAC, in addition to performance-based incentives, for their full-time work. Each Shasthya Kormi supervises 10 to 12 Shasthya Shebikas. The Shasthya Shebika meets with her supervising Shasthya Kormi two to three times each month. BRAC program organizers typically supervise five Shasthya Kormis. A medical doctor attends Shasthya Shebikas' meetings with their supervising program organizer, providing further guidance.

 

BRAC program overview

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

STEPS INDIVIDUAL DATA COLLECTION DATA REPORTING

1          

Shasthya Shebika (SS)

SS collects/prepares:

  • Medicine sales
  • Health commodity sales
  • Plan for household visit
  • Information on household visit

Reports information in registrars to Shasthya Kormi on a regular basis

SS reports to SK

2          

Shasthya Kormi (SK) 

SK collects the following information in one registrar (incorporating data from SS):

  • Demographic (population, HHs, age disaggregated) information
  • FP data (total, adolescent, FP method user, new user, BRAC contribution)
  • Maternity data (identification, four+ ANC, one PNC, delivery, institutional delivery and skilled delivery)
  • Child health and nutrition (vaccination, diarrhea, pneumonia, EIBF, EBF and CF)
  • Education and counseling (forums and participants)
  • Services packages (number of clients received services for ANC, adolescent health)
  • IYCF and women's health

Monthly compilation of services distributed at branch level

SK reports to program organizer

3 Program Organizer (PO) 

Collects data in registers, focus on supply chain:

  • Register of health commodities (medicine sales information, medicine purchases and bill payment, revolving fund and presence of participants in refreshers)
  • Stock register
  • Daily buy and sell register (medicines, health commodities, glasses, pushtikona)

Monthly compilation at branch level including PO register and aggregated data from all SK that he/she supervises

PO reports this data to the upazila manager

4 Upazila Manager (UM)
  • Collects data from the report of program organizer, maternity/ delivery center (outdoor consultation, delivery, referral, FP services), vision center (outdoor consultation, glasses and medicine sales, referral for surgeries)
  • Manages some register: stock register, petty cash register, meeting minutes register

Makes monthly report for upazila, including: program performance report, financial report, HR report, data from PO synthesis of SK service delivery

Sends to district manager

5 District Manager (DM) Collects and compiles reports from upazila managers of respected District. Enters data in digital system producing district report
6 Central Level Automated compilation of data at district, division and national level
Data source for table:  BRAC

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
  • Health Assistants
  • Community Health Care Providers 

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.

  • Family Welfare Assistants

    Since the program’s launch in 1976 as the first cohort of CHWs in Bangladesh to address the national priority of improving access to birth control, the number of Family Welfare Assistants has grown from 13,500 to the current 20,000.

    These women now spend about half their time working in community clinics and the other half making house calls. FWAs primarily focus on distributing family planning services and maternal and neonatal health. They offer pills, condoms, and injectable birth control. They assess pregnant women’s nutrition and provide deworming, iron, and folic acid supplementation, as needed. They also promote immunization, antenatal care, prenatal care, and educate mothers on oral rehydration solution.

  • Health Assistants

    Bangladesh’s 17,000 Health Assistants also spend about half their time working in the community clinic, and half their time making house calls. They focus on organizing immunization campaigns, including educating communities about the need for and the importance of immunization. They also focus on improving children’s health through preventive measures such as Vitamin A supplementation and the detection and treatment of common diseases and illnesses in children such as acute respiratory infection (ARI), diarrhea, tuberculosis (TB), and malaria.

  • Community Health Care Providers

    Launched in 2009 with the establishment of Bangladesh’s community clinics, the 13,000 Community Health Providers are the only CHWs in Bangladesh with clinical training who can, therefore, provide a higher level of services. Working full-time at the community clinic, Community Health Care Providers provide the widest range of preventive, promotive, and curative care. They manage cases of childhood diarrhea, pneumonia, and malaria, screen for malnutrition and provide newborn care. They also provide care to pregnant women, including the management of anemia, ANC, and PNC. They attend deliveries. Like both of the other government CHW cohorts, they also make referrals for more complex care.

The Family Welfare Assistants and Health Assistants both receive one month of training, though their training differs. Community Health Care Providers receive three months of training.

Despite the varying levels of training and responsibilities, all three cadres are paid $182 per month. This salary reflects, in part, the relatively flat pay scale of government workers in Bangladesh. And all three cadres work, at least part-time, side by side at the local community clinic. The Community Health Care Provider works in the clinic exclusively, full-time.

There are multiple layers of supervision for the three CHW cohorts. A community group directly oversees the management of the community clinic and CHWs that work there. Just above that, at the union level, Health Assistants and Community Health Care Providers receive direct supervision from assistant health inspectors, and Family Welfare Assistants receive direct supervision from family planning inspectors. One level up from this at the upazila or sub-district level, all government CHWs attend monthly health meetings. And, at the national level, community clinics report data into the national Health Management Information System.

Government program overview

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.

“A key success factor of our work is monitoring and evaluation. We are constantly producing data and seeking to better understand community context. I would say that the CHW is the first researcher in the community because they are constantly interacting with community members. They understand what the need is in the community and they help us continuously adapt our services to meet these changing needs.”

-  Multilateral institution stakeholder4

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.

Regular health worker house calls are vital to compiling household data and promoting community presence.
©Gates Archive

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.

Community health worker density and immunization coverage

Data Source: Institute for Health Metrics and Evaluation (IHME); Demographic and Health Surveys (DHS)

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

Oral rehydration solution (ORS) coverage

Data Source: Institute for Health Metrics and Evaluation (IHME); Demographic and Health Surveys (DHS)

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 clinic reach

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.

Community clinic and annual clients per 10,000 population

Data Source: Ministry of Health and Family Welfare (MOHFW) of Bangladesh

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.

Proportion of births attended by skilled health personnel

Data Source: Institute for Health Metrics and Evaluation (IHME)

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

Community clinics are the hallmark of health workers’ engagement in small localities in Bangladesh. 
©Gates Archive

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.

“We can’t speak about community health without speaking about how the community views women, and that’s why we started to think about this work as integrated and more about poverty reduction than just health, and this requires female empowerment and shifting how society views these women.”

- NGO leader 4

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.

A health worker in Bangladesh teaches new mothers a class.
Hiring women as health workers helps shift social norms by placing women in leadership positions in the community. 
©Gates Archive

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

"I really feel that the CHW efforts, the education that we have prioritized for them in our country, have shifted how we view women. They are seen now as sources of income for their families and a lot of that has to go to the credit of literacy, microfinance, education programs as well. All this has changed values that ultimately has supported better health outcomes.”

- NGO leader 8

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

“The earnings from Shebika activities have assisted me to become economically independent. From this earning I meet the expenditure of my children’s education and other necessities; once I even managed to run my family on this income when my husband was bedridden due to an accident…”

-  Shasthya Shebika 22

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

CHARACTERISTICS SHASTHYA SHEBIKA (SS) SHASTHYA KORMI (SK)

Scale (Latest)

  • Scale (Latest)
    ~42,000
  • ~4,000

Ratio

  • Rural population: 1:2,000
  • Rural Population: 1:25,000
Qualifications
  • Female; 25 years or older; youngest child is not < two years old; socially acceptable to village; family agrees to her involvement
  • Married; acceptable to their community and have passed grade 10 in school
Selection
  • Mostly self-selected by VO; local Gram committee also play a role in nominating prospective SSs; BRAC makes final selection
  • Selected by BRAC
Training
  • Three-four weeks pre-service training; additional special training every quarter (2-5 days depending on need) for TB DOTS, diagnosis and treatment of pneumonia, and safe motherhood
  • Monthly refresher training
     
  • Three-four weeks pre-service training
  • Monthly refresher training
Services 

SSs are expected to visit 250-300 households per month or approximately 10-30 homes per day ( ~4hs of work per day). Household visits include identifying health needs (i.e. pregnancy), disseminating health messages, motivating service use and monitoring and referring as necessary. The SS regularly shares this household information with the SK, who tracks it in a registrar

  • Health promotion and education: WASH, nutrition, FP, pregnancy related care, childhood immunization
  • Community Mobilization: National immunization, vitamin A and deworming campaigns; immunization and FP satellite clinics
  • Treatment of common ailments: Fever, cold, anemia, peptic ulcer, diarrhea, amoebic dysentery, scabies, pneumonia
  • Other medical duties: Early diagnosis and treatment of malaria, ARI, TB suspects (DOTS), identify pregnant women and refer to SK
  • Sale of drugs and health commodities: Paracetamol, vitamins, anti-histamines, ORS, antacids, iodized salt, sanitary napkins, condoms, contraceptive pills, safe delivery kits, reading glasses. SS procure supplies during the monthly refresher trainings from the BRAC office, local shops or BRAC production centers. BRAC produces sanitary napkins, delivery kits and iodized salt. BRAC works with pharma to procure commodities for their offices, earning a small markup on the products
  • Conduct health education sessions
  • Provide ANC and PNC, assist with deliveries
  • Provide essential newborn care, including special care for low birth weight babies
  • Offer community-based management of acute malnutrition; manage diarrhea and acute respiratory infections of children
  • Oversee TB treatment and conduct immunization programs
     
Supervision
  • Shasthya Komi (SK); One SK supervises approximately 10-12 SS; Each SS engages with their respective SK two-three times per month
  • SK provides feedback to the SS at the monthly refresher training using individual performance report
  • BRAC analyzes performance data from reports to understand current health situation and performance challenges
  • There is also an independent monitoring department that measures inputs and outputs, and quarterly performance
  • Part-time, generally working three-five hours per week
  • Establish and lead a one-to-five network or WDG
  • Program organizers (PO) who are supervised by Area Program Manager and a medical doctor
  • POs, SK, SS and medical doctor all attend monthly refresher training/performance meeting
Incentives
  • Access to an additional microfinance loan from BRAC
  • Income from selling medicines and health products as well as performance-based incentives for identifying pregnant women and signing them up for antenatal care delivered by the SK, ensuring adherence to TB DOTS and referring individuals to health facilities
  • SS generally earn income of ~$25 per month; 86 percent became SS to earn income
  • Regular monthly salary of ~$50 per month + performance-based incentives
Start Date 
  • 1991 (early iterations started in mid-1970s)
  • 2005
Evolution
  • 1970s and 1980s: family planning, OTEP and EPI, Vitamin A and WASH education
  • 1990s: formalization as part of EHC, IMCI and MNCH, and TB
  • 2000s: supervision by SKs
  • 2000s: focus on MNCH program
  • 2010s: greater focus on health packages and education

 

GOVERNMENT CADRES

CHARACTERISTICS FAMILY WELFARE ASSISTANTS (FWA) HEALTH ASSISTANTS (HA) COMMUNITY HEALTHCARE PROVIDER (CHCP)

Scale (Latest)

~20,000

~17,000

~13,000

Ratio

  • Design: 1:7,000-10,000 (CC catchment); originally 6k
  • Rural population: 1:5,500
  • Design: 1:7,000-10,000 (CC catchment); originally 6k
  • Rural population: 1:6,500
  • Design: 1:7,000-10,000 (CC catchment); originally 6k
  • Rural population: 1:8,000
Qualifications
  • Female, 10 years of schooling and a local resident
  • Male or Female, 10 years of schooling, local residentMale or Female, 10 years of schooling, local resident
  • Male or Female, 10 years of schooling, local resident, capable of operating a computer
Selection
  • Selected and managed by Directorate General of Family Planning
  • Selected and managed by DGHS
  • Selected and managed by Directorate General of Health
Training
  • 3 weeks; ad-hoc refresher training (1-2 days)
  • Some FWAs receive additional 6 months training to become community skilled birth attendants.
  • 3 weeks; ad-hoc refresher training (1-2 days)
  • Some female HAs receive addt’l 6 months training to become community skilled birth attendants.
  • 6 weeks theoretical/6 weeks practical ad-hoc refresher training (1-2 days); CHCP is only provider that is considered to have clinical training
  • Some female CHCPs receive addt’l 6 months training to become community skilled birth attendants.
Services
  • Community Clinic (50%): Support CHCP in all activities; focus on family planning and maternal health
  • Outreach (50%): Visit households 1X/ 2 months; register couples and pregnant mothers, record deaths and births; mobilize demand for and dispense short-term family planning products (pills, condoms, depo); provide family planning and nutrition counselling and to a lesse extent promote EPI/ANC/PNC/CBNC and ORS; refer upstream.
  • Community Clinic (50%): Support CHCP in all activities; focus on EPI and children’s health
  • Outreach (50%): Visit households 1X/ 2 months; mobilize demand for eight designated “EPI sites”; provide vitamin A supplements and ORS; detect and treat ARI, diarrhea, TB and malaria, usually at the community clinic; conduct health promotion; provide referrals to upstream clinics.
  • Community Clinic (100%): Provide basic preventive, promotive and curative care (ANC, PNC, CBNC, family planning, first aid, pneumonia, anemia); dispense medicines; some perform normal deliveries at the community clinic; referral to upstream facilities.
Supervision
  • Family planning inspectors and assistant family planning inspectors (~2x/month); CG also provides oversight.
  • Health inspector and assistant health inspectors (2x/month); CG also provides oversight.
  • Health inspector and assistant health inspectors (2x/month; CG also provides oversight.
Incentives 
  • Salaried civil servants: US$ 182/month
  • Salaried civil servants: US$ 182/month
  • Salaried civil servants: US$ 182/month
Start Date 
  • 1976
  • 1960s
  • 2010
Evolution 
  • 1970s: Emerged as key investment in reducing fertility rate by increasing contraceptive prevalence
  • 1980s: EPI/ORS targeted towards women
  • 1990s and 2000s: Begin to work at community clinic 50% of the time and receive CSBA training
  • 1960s: Malaria and smallpox vaccinators
  • 1980s: EPI/ORS
  • 1990s and 2000s: Begin to work at community clinic 50% of the time and receive CSBA training
  • 2000s: TB Program/Community Clinic /CSBA
  • 2000s: Community Clinic and training as community skilled birth attendance (CSBA)
Note: Multipurpose Volunteers (MPV), under proposal. Currently, there is a proposal under consideration to staff five community health volunteers in the catchment area of each community clinic to help conduct community outreach and surveillance. They would be paid through performance incentives rather than a full-time salary, and would be managed by the DGHS, but selected by the community.

COMPLETE GOVERNMENT AND BRAC ESSENTIAL HEALTH SERVICE PACKAGE

CHARACTERISTICS FAMILY WELFARE ASSISTANTS (FWA) HEALTH ASSISTANTS (HA) COMMUNITY HEALTHCARE PROVIDER (CHCP) SHASTHYA SHEBIKA (SS) SHASTHYA KORMI (SK)

Health Promotion and Education

  • WASH
  • Family planning
  • Nutrition
  • Pregnancy and newborn-related care (ANC/PNC/CBNC)
  • WASH
  • Infectious diseases (HIV, TB, malaria)
  • Nutrition
  • Child health
  • NCDs (hypertension, diabetes, cancer, smoking)
  • Mental health
  • WASH
  • Family planning
  • Nutrition
  • Pregnancy and newborn-related care (ANC/PNC/CBNC)
  • Child health
  • NCDs (hypertension, diabetes, cancer, smoking)
  • Mental health
  • WASH
  • Family planning
  • Nutrition
  • Pregnancy and newborn-related care (ANC/PNC/CBNC)
  • Child health
  • WASH
  • Family planning
  • Nutrition
  • Pregnancy and newborn related care (ANC/PNC/CBNC)
  • Child health

Community Mobilization

  • Mobilize community members to attend national immunization, vitamin A, and deworming campaigns
  • Mobilize community members to attend immunization and family planning satellite clinics
  • Mobilize community members to attend national immunization, vitamin A, and deworming campaigns
  • Mobilize community members to attend immunization and family planning satellite clinics
  • Mobilize community members to attend national immunization, vitamin A, and deworming campaigns
  • Mobilize community members to attend immunization and family planning satellite clinics
  • Mobilize community members to use community clinic services via community groups

  • Mobilize community members to attend national immunization, vitamin A, and deworming campaigns
  • Mobilize community members to attend immunization and family planning satellite clinics
  • N/A
Family Planning
  • Register and visit all eligible couples
  • Distribute short-term family planning methods (oral contraceptives, condoms, depo)
  • Identify and refer clients for IUD and permanent methods
  • N/A
  • Distribute short-term family planning methods (oral contraceptives, condoms, depo)
  • Identify and refer clients for IUD and permanent methods
  • Sell short-term family planning methods (oral contraceptives, condoms, depo)
  • N/A
Maternal and Neonatal Child Health 
  • Register and visit all pregnant women
  • Conduct birth preparedness plan
  • Assess pregnant women's malnutrition status and conduct deworming as needed for pregnant women
  • Provide iron and folic acid supplementation
  • Provide tetanus toxoid vaccine at EPI outreach sites
  • Refer to community clinic and other clinics for ANC and PNC services
  • Identify and refer clients for obstetric emergencies/fistula
  • Identify and refer clients for newborn challenges, such as sepsis
  • Provide tetanus toxoid vaccine at EPI outreach sites
  • Identify and diagnose pregnancy
  • Registration of pregnancy
  • Provision of ANC and PNC
  • 30 percent conduct normal delivery and community based newborn care
  • Identify, manage, and refer clients for obstetric emergencies/fistula
  • Identify, manage, and refer postnatal complications
  • Provide detection and referral for severe reproductive health problems
  • Identify pregnant women and refer to SK
  • Identify high-risk pregnancies
  • Sell sanitary napkins
  • Provide ANC and PNC
  • Refer women for tetanus toxoid vaccination
  • Monitore nutrition and provide supplemental food for low birth infants
  • Assist with deliveries
Child Health
  • On an ad hoc basis, support health assistants and community healthcare provider with child health and immunization
  • Activities are same as health assistants
  • EPI: Conduct EPI at eight designated EPI “sites” within coverage area
  • Counsel parents on immunization and adverse effects, register children and follow up
  • Provide vitamin A supplements
  • IMCI: Provide counseling to parents on danger signs, nutrition of sick child; identify danger signs and refer
  • Detect, treat and manage mild ARI with cotrimoxazole (work with CHCP)
  • Detect, treat and manage mild diarrhea with ORS (work with CHCP)
  • Screen for malnutrition
  • Prevent malnutrition through breastfeeding, deworming, micronutrient supplementation
  • Manage moderate, severe acute malnutrition (uncomplicated)
  • EPI: Conduct EPI at the community clinic
  • Counsel parents on immunization and adverse effects, register children and following up with defaulters
  • IMCI: Provide counseling to parents on danger signs, nutrition of sick child; identify danger signs and refer
  • Detect, treat and manage mild ARI with cotrimoxazole/amoxycillin
  • Detect, treat and manage mild diarrhea with ORS and zing
  • Conduct growth monitoring
  • Screen for malnutrition
  • Prevent malnutrition through breastfeeding, deworming, micronutrient supplementation
  • Manage moderate and severe acute malnutrition (uncomplicated)
  • Manage mild anemia
  • Provide prevention, treatment and referral for fever, common cold, anemia, peptic ulcer, diarrhea, dysentery, scabies and pneumonia/ARI
  • Provide essential newborn care
  • Sales of ORS sachets and zinc tablets; cotrimoxazole
  • Provide essential newborn care, including special care for low birth weight babies
  • Offer community based management of acute malnutrition
  • Manage diarrhea
  • Manage acute respiratory infections
  • Conduct childhood immunization
Communicable Diseases
  • On an ad hoc basis, help support health assistants and community healthcare provider with communicable disease prevention, detection and treatment
  • Activities are same as health assistants
  • Detect, treat and manage malaria with antimalarials uncomplicated first line (work with CHCP)
  • Detect and treat TB with DOTS
  • Refer for HIV counseling and testing
  • MDA for lymphatic filariasis
  • Detect, treat and manage malaria with antimalarials uncomplicated first line
  • Detect and treat TB with DOTS
  • Prevention of HIV infection
  • Refer for HIV counseling and testing
  • MDA for lymphatic filariasis
  • DOTS oral treatment for Kala-Azar
  • Provide diagnosis and treatment of malaria
  • Identify TB suspects, referral for sputum examination, ensuring DOTS for TB patients
  • Sell antimalarial and bed–nets
  • Oversee malaria treatment
  • Oversee TB treatment
Non-Communicable Diseases 
  • Counsel on screening for cervical and breast cancers
  • Teach breast self-exam
 
  • Screen for hypertension, diabetes
  • Screen for risk factors of CVD
  • Counsel on screening for cervical and breast cancers
  • Clinical breast exam
   
Other 
  • Support CHCP in all activities; focus on family planning and maternal health
  • Record deaths and births
  • Refer for other maternal health services
  • Case identification and reporting of sexual violence
  • Support CHCP in all activities, focus on EPI and children’s health
  • Refer for other childhood health services
  • Help respond to emergencies
  • Case identification and reporting of sexual violence
  • Referrals for more complicated services
  • Detection and treatment of minor ailments like headache, fever, cold, and cough, eye and ear care
  • Treatment of scabies and ringworm
  • Provide basic first aid
  • Case identification and reporting of sexual violence
  • Sales of the following vitamins and medicines: Paracetamol, antihistamines, antacids, vitamins A and B, iron supplements, multivitamins, iodized salt, sanitary napkins, reading glasses., antiseptic ointment and antiseptic liquid mebendazole and albendazole (deworming), and diapers
  • Supervise SS

 

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How did Bangladesh implement?