By: Dena Javadi and Jessica Gergen, students in the Johns Hopkins Bloomberg School of Public Health, and Henry Perry
Case Studies of Large-Scale Community Health Worker Programs was derived from the Developing and Strengthening Community Health Worker Programs at Scale: A Reference Guide and Case Studies for Program Managers and Policymakers, edited by Henry Perry, Lauren Crigler, and Steve Hodgins.
Originally published in May 2014 by USAID’s flagship Maternal and Child Health Integrated Program (MCHIP), it was created in response to the rapid increase in and expansion of CHW programs in low- and middle-income countries over the past decade. In January 2017, a companion document was prepared to provide guidance on 13 case studies, including Afghanistan, Bangladesh, Brazil, Ethiopia, Niger, India, Indonesia, Iran, Nepal, Pakistan, Rwanda, Zambia, and Zimbabwe. CHW Central is serializing the case studies over time.
The next case is about Bangladesh.
Bangladesh has a history of using CHWs to support health services. BRAC has been a driving force and has been refining its strategies.
The Shasthya Shebika (SS) Program is rooted in a gendered perspective, focusing on the need for female health workers in Bangladesh to address socio- cultural barriers to access to health care services. BRAC first adopted the Barefoot Doctor approach used in China a half-century ago and trained male paramedics, but then shifted the approach in the early 1980s to focus on women with lesser training who were often illiterate.
In 1990, there were 1,080 SSs, and by 2008 the number had grown to 70,000. At present, there are approximately 100,000 SSs.
SSs receive four weeks of basic training by the local BRAC office. They are trained to treat common medical conditions, to promote a wide variety of health behaviors, and to refer patients to preventive and curative services as appropriate.
During monthly household visits, SSs provide health promotion sessions and educate families on nutrition, safe delivery, FP, immunizations, hygiene, and water and sanitation. They also use this time to sell health products, such as basic medicine, sanitary napkins, and soap. BRAC introduced the sales component to provide a small profit as an additional incentive for and motivation to the Community Health Volunteers (CHVs) to continue working. When someone has an illness that the SS cannot manage, the person is referred to government health centers or a BRAC clinic.
CHVs are given small loans to establish revolving funds, which they use to make some money by selling health products at a small markup.
Direct supervision is conducted by higher-level CHWs called Shasthya Kormis (SKs). Other program staff at BRAC also provide supervisory support.
The program is self-sustaining and is widely perceived to have made an important contribution to Bangladesh’s remarkable progress in reducing under-5 mortality and to its national TB control program.
What is the historical context of BRAC’s Shasthya Shebika Program?
Community-based programming with CHWs has been widespread in Bangladesh, especially through the national implementation of Bangladesh’s well-known and highly successful national family program. This program relied on FWAs to visit every home on a regular basis to promote the uptake of FP at a time when women were not able to leave the immediate environs of their home. BRAC set up the CHV program to address the health needs of the communities where it works. BRAC community-based integrated programs now reach more than 110 million people in Bangladesh.
The development of the SSs Program has been deliberate, slow, and organic. There was no preconceived national blueprint that was scaled up rapidly. Rather, a viable role was established for these CHWs appropriate for the Bangladeshi context, and BRAC found a way to provide sufficient locally generated financing to motivate the women to carry out their responsibilities. Then, as BRAC was able to provide appropriate training and supervision, the program began to grow over the course of two decades.
What are Bangladesh’s health needs?
The health status of the poor and vulnerable remains challenging, and families may suffer financial catastrophes if a member falls ill. Communicable diseases, poor MCH, and malnutrition are responsible for high levels of preventable morbidity and mortality. New challenges of the epidemiological shift to chronic and non-communicable diseases are arising, along with environmental hazards from air and water pollution, injuries, and unhealthy behaviors such as tobacco use and violence.
What is the existing health infrastructure?
While officially Bangladesh has a health system involving a three-tier service delivery system from the Ministry of Health and Family Welfare (MOHFW) with a comprehensive network of public facilities at tertiary, secondary, and primary levels, in practice it is quite pluralistic and unregulated, with low utilization of public sector health centers and district hospitals.2 There is a mix of public, private, NGO, and traditional providers. These all have different reach and quality, and the public sector is responsible for less than 20% of curative services. The public and private sector have a porous boundary and doctors move between the sectors. Village doctors (informally trained providers who practice allopathic medicine) are the dominant providers of care at the community level.
What type of program has been implemented?
BRAC started in the early 1970s by adopting the Barefoot Doctor approach first used in China, but applying it to male paramedics. This approach failed, and BRAC shifted to lesser-trained female CHWs, often illiterate, who were oriented to health promotion and disease prevention.
At present, SSs work part-time in the afternoon, providing services to an average of 250–300 households through monthly household visits.2 SSs serve as the primary source of health information for their particular catchment areas. They also collaborate with trained traditional birth attendants (TBAs) in the village as well as mobilize women to participate in national disease control campaigns, come to clinics for basic MCH services, and carry out growth monitoring of children.
During the monthly household visits, SSs provide health promotion sessions educating families on safe delivery, FP, immunizations, hygiene, and water and sanitation. They also use this time to sell health products, a component introduced by BRAC to increase the incentives for and motivation of SSs. When someone has an illness that the CHV cannot manage, the person is referred to government health centers or a BRAC clinic.
Other activities that SSs carry out include the following:
- Identifying pregnancy
- Providing ANC including supplemental food to malnourished pregnant women
- Identifying high-risk pregnancies
- Referring women for tetanus toxoid immunization
- Referring women to a trained TBA for delivery
- Providing postnatal care (PNC)
- Promoting exclusive breastfeeding during the first 5 months of life and continued breastfeeding with appropriate weaning foods thereafter
- Monitoring nutrition and providing supplemental food for low-birth-weight infants when the infant reaches 6 months of age
- Promoting vitamin A supplementation at the time of national campaigns for vitamin A supplementation for children 12–59 months of age
- Providing health and nutrition education and nutritional surveillance for adolescent girls (11–16 years of age)
- De-worming children
- Treating uncomplicated acute illnesses
- Promoting awareness about reproductive tract infections and AIDS
SSs link into the formal MOHFW system in important ways. They mobilize women and children in the catchment areas to attend satellite clinic sessions when a mobile government team comes to give immunizations and provide FP services, usually once a month. They also mobilize their clientele to participate in the national government’s health campaigns and usually serve as outreach workers for special campaigns such as vitamin A distribution and de-worming. In addition, SSs identify patients with symptoms suggestive of TB and, on selected days, collect sputum specimens from them. A second-level supervisor (the program organizer) takes these specimens to the district health facility, where they are tested. Then, patients who tested positive are given DOTS by the SS under authorization from the MOHFW (Akramul Islam, personal communication, 2013).
What about the community’s role?
SSs are accepted by the community because they are from the community, answerable to the communities for their activities, and supported by the health system through both BRAC and the government. They serve as health promoters, as the first point of care, and as sellers of medical products.
How does BRAC select, train, and retain Shasthya Shebikas?
BRAC works at the village level through Village Organizations, which are small groups of women who participate in BRAC’s microcredit savings and loan program. SSs are self-selected from within these groups.2 The identification of prospective SSs is made first by the Gram Committee, which is the local village health and development committee. The Gram Committee is made up of 8–10 women, 1 SS, and 1 TBA. The final selection is made by BRAC staff together with local village leaders and government officials.1 To be an SS, a woman must be supported and selected by the community, between the ages of 25 and 35, married with no children younger than five years, and motivated; have some schooling preferably; and not live near a health care facility or large bazaar, which would create competition.
CHVs receive four weeks of basic training by the local BRAC office. They are trained on treatment of everyday conditions such as skin and eye infections, common cold and cough, and diarrhea and other abdominal complaints. Some are additionally trained to detect symptoms suggestive of TB and provide drugs to patients who are diagnosed with TB. Many SSs are also trained to diagnose and treat pneumonia in children. Refresher training, done in an interactive and problem-solving way, is central to BRAC’s method and serves to keep the knowledge of SSs updated, provide opportunities for discussion of problems, and facilitate regular contact; it also allows SSs to replenish supplies including drugs.
How does BRAC supervise its Shasthya Shebikas?
SSs are supervised by SKs, who are also recruited from their communities. SKs are paid a sum equivalent to about $40 per month to supervise the SSs and perform ANC in villages. The SKs, all women, have a minimum of 10 years of schooling and work between 4 and 5 hours per day. They accompany each of the SSs in their charge on community visits at least twice per month and meet monthly with their group of SSs to discuss problems, gather information, and provide supplies and medicines. BRAC program staff members also participate in supervision. There is a formal link to the local government’s health service delivery system for referral when necessary.
How is the program financed?
SSs earn an income from selling supplies such as oral contraceptives, birthing kits, iodized salt, condoms, essential medications, sanitary napkins, and vegetable seeds at cost plus a small markup. They receive incentives for good performance that are based on achieving specific objectives during that month, such as identifying pregnant women during their first trimester.
Supervisors verify and monitor performance during their visits to communities, where they have the chance to talk with village women. Like most other program activities at BRAC, the SS Program is subsidized by income-generating activities that BRAC operates at scale, including commercial enterprises in handicrafts, milk and poultry production, printing, and banking.
What are the program’s demonstrated impact and continuing challenges?
Supervisors track SS performance, and BRAC provides support to address challenges as they occur. One formal study assessed how well SSs managed childhood pneumonia using the protocol approved by the World Health Organization (WHO); the study revealed the SSs performed as well as physicians in implementing this protocol. Another formal study compared the prevalence of TB in districts where SSs were identifying suspected cases and providing DOT for those diagnosed with TB and demonstrated that the prevalence of TB in BRAC areas was half of that in control districts.
Challenges of supervision, livelihoods, accountability, and focus are mostly addressed with systematic supervision, logistic support, and formal links to the health system. SSs still struggle for legitimacy in the pluralistic health environment, where they may be viewed as second-rate and not as good as doctors.
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Standing H, Chowdhury AM. Producing effective knowledge agents in a pluralistic environment: what future for community health workers? Soc Sci Med. 2008;66(10):2096- 2107.
Mahmood SS, Iqbal M, Hanifi SM, Wahed T, Bhuiya A. Are ‘Village Doctors’ in Bangladesh a curse or a blessing? BMC Int Health Hum Rights. 2010;10:18.
Hadi A. Management of acute respiratory infections by community health volunteers: experience of Bangladesh Rural Advancement Committee (BRAC). Bull World Health Organ. 2003;81(3):183-189.
Chowdhury AM, Chowdhury S, Islam MN, Islam A, Vaughan JP. Control of tuberculosis by community health workers in Bangladesh. Lancet. 1997;350(9072):169-172.