Community Health Workers in Bangladesh

Community health workers (CHWs) are the primary healthcare providers the community level in Bangladesh. The Bangladesh Rural Advancement Committee (BRAC), with the support of Alive & Thrive, has trained and employs over 100,000 CHWs who bridge the gap between the public healthcare system and the community. They receive training in breastfeeding/infant and young child feeding practices. Alive & Thrive estimated 37,400 mothers were counseled on breastfeeding and exclusive breastfeeding rates rose from 51% in 2010 to 83% in 2013 in the program areas. Now a proven method to improving health outcomes, Bangladesh strongly supports its CHW program nationwide– BRAC’s 2016 report cites 2 million new mothers were counseled on exclusive breastfeeding.

Description & Context

While the Ministry of Health in Bangladesh provides public health facilities at all levels, many poor and rural citizens cannot access these (1). In fact, the public sector provides less than 20% of curative services and a majority of women give birth at home (1,8). Community and village health workers are the primary providers of care at the community level (1). Bangladesh Rural Advancement Committee (also known as Building Resources Across Communities, BRAC), with the support of Alive & Thrive (A&T), has trained and currently employs over 100,000 community health workers (CHWs), specifically, Shashthya Shebikas (SS) who are females from the community (1, 2). These CHWs and SS are essential to bridge the gap between formal healthcare systems and the community, and receive training in breastfeeding/infant and young child feeding (IYCF) practices (2).

In 2009, A&T set the goal of improving the health of 3.5 million Bangladeshi children under two years old by 2013 (3). Their research indicated this would be most easily achieved by the improvement of IYCF practices through face-to-face communication in the community (3). To reach their target and maximize the numbers of children and mothers exposed to the communications, A&T supported and initiated the training of 11,000 BRAC CHWs in infant and young child feeding (3). They estimated 37,400 mothers were counseled on breastfeeding and exclusive breastfeeding rates rose from 51% in 2010 to 83% in 2013 in the program areas (3). In addition, the child mortality rate dropped from 50 per 1,000 in 2010 to 42 per 1,000 in 2013 and the prevalence of moderate-severe stunting dropped from 41 to 36% (4,5).

Now a proven method to improving health outcomes, Bangladesh strongly supports its community health worker program– BRAC’s 2016 report cites 2 million new mothers were counseled on exclusive breastfeeding (2).

Main Components

The implementation manual for BRAC’s community-based A&Ts IYCF program in Bangladesh describes the four core community health interventions and the service providers who deliver these interventions (6):

Interventions:

• Home visits
• Antenatal and postnatal care visits
• Health forums
• Social mobilization

Service Providers:

• Shasthya Shebikas (SS- BRAC female community health volunteers): Female volunteers, selected from village health and development committees. They are officially confirmed as SS by a multi-sectorial group comprised of BRAC staff, local village leaders, and government officials. The woman must be between 25 and 35, married with no children under five years old, and be clearly supported as a candidate by the community (1).
• Shasthya Kormis (SK - Employed BRAC community health workers): SS supervisors.
• Pushti Kormis (PK - IYCF promoters): Hired by BRAC to support the SS and SK.
• Program Organizers: Employees of BRAC’s health program to supervise the SS, SK and PK providers and conduct social mobilization sessions.

The following describes the specific roles and responsibilities of the SS, who are the most abundant and are stipulated to contact pregnant women and children under two years of age once a month until the child reaches age two (6):

• Counsel on, promote, and ensure the initiation of breastfeeding for new mothers within one hour of birth;
• Counsel on, promote, and ensure exclusive breastfeeding for the first sixth months;
• Counsel on, promote, and ensure the introduction of appropriate sanitary complementary food for children 7-12 months;
• Counsel on, promote, and ensure hand washing with soap by the mother and child before feeding;
• Identify and solve IYCF-related difficult cases, referring to the Pushti Kormis if necessary; and
• Deliver micronutrient powders to households.

The roles and responsibilities of the SK differ from the SS in that they specifically focus on pregnant women in the antenatal and postnatal periods. Specific roles and responsibilities include (6):

• Identify and register pregnant women;
• Counsel women during the antenatal period to initiate breastfeeding within the first hour of birth, then continue to exclusively breastfeed until the child is 6 months of age;
• Support mothers for proper attachment and positioning in the antenatal and postnatal period; and
• Discuss recommended IYCF practices with mothers, particularly in community health forums

SS receive four weeks of training from a local BRAC office on an array health issues (1). Training of the SS, SK, and PK in IYCF specific practices occurs over 3 days in a classroom setting, with a curriculum from a combination of the WHO/PAHO Guiding Principles for Complementary Feeding of the Breastfed Child (2003), WHO’s Infant and Young Child Feeding Counseling: An Integrated Course (2006), and AED’s Essential Nutrition Actions training module (6,7). The curriculum is presented through lectures, video, group discussion, role play, experience sharing, and more. Following this classroom training, the SS receive one day in the field with master trainer supervision. SK and PK receive an additional two days of field training. To pass the training, under master trainer observation, the SS, SK, or PK must counsel a mother with young children in 2-3 key practices as well as help her to demonstrate recommended practices such as breast attachment, breastmilk expression, and food preparation for older infants (6).

Specific technical content and skills learned in the training are (6):

• Initiation of breastfeeding within the first hour
• Benefits of breastfeeding
• Positioning and attachment
• Expression of breastmilk
• Preventing and overcoming breastfeeding difficulties
• Basic counseling techniques
• Importance of timely and appropriate age-specific complementary feeding
• Amount, frequency, consistency, composition, and preparation of appropriate complementary foods
• Complementary feeding difficulties and their management
• Maternal nutrition
• Providing IYCF support at community and household level
• Identifying and managing feeding difficulties
• Negotiating improved practices to help mothers identify and resolve problems
• Counseling, coaching, and demonstration skills

SS, SK, and PKs meet once a month to review progress and exchange lessons learned among other practical tasks and four times per year, they receive refresher training (6).

Evidence of Implementation Strategy

Alive & Thrive estimated 37,400 mothers were counseled on breastfeeding per month through the 2009 initiative, and exclusive breastfeeding rates rose from 51% in 2010 to 83% in 2013 in the program areas (3). Child mortality also dropped from 50 per 1,000 in 2010 to 42 per 1,000 in 2013, and the prevalence of moderate-severe stunting dropped from 41 to 36% (4,5). The BRAC 2016 report cites 2 million new mothers were counseled on exclusive breastfeeding (2).

The evidence is backed by qualitative studies; a study in Bangladesh on community health workers found that after a home visit by a community health worker, a mere 6% of infants had feeding difficulties versus 34% who did not have a community health worker visit (8).

Cost and Cost-Effectiveness

The SS program is subsidized by the income-generating activities BRAC operates at large-scale such as commercial enterprises in handicrafts, milk (following the Code stipulations), poultry production, printing, and banking (1). There is also a performance incentive for SSs, who receive $2.50-$6.70 per month from the sale of health products at a small markup and approximately $5.50 from IYCF performance-based incentives (1,6). SKs are paid approximately $40 per month to supervise SSs and perform antenatal and postnatal care in the villages (1).

Concerning Alive & Thrive’s monthly meetings and refresher trainings, Alive & Thrive covers transportation costs and provide food to encourage attendance (6). They also distribute cash performance incentives at the monthly meetings to increase attendance (6).

Perceptions and Experiences of Interested People

The national training manual for IYCF in Bangladesh begins with messages from Bangladesh high officials such as the Minister of the Ministry of Health and Family Welfare and the Director of the Institute of Public Health Nutrition. These messages all contain emphasis on the training of health care workers at the community level, stating they “strongly believe that managers, trainers, and community level service providers will use this manual and play an important part in sustainable nutritional development for infant and young children in Bangladesh” (7).

In addition, a 2008 study in Bangladesh questioning whether early postpartum home visits by community health workers improved the health of newborns clearly found improvements in feeding practices with community health worker intervention. Thus, there is accepted evidence in Bangladesh that counseling and hands-on support on feeding techniques by community health workers should be incorporated into the health model (8).

Benefits and Potential Damages and Risks

• It is essential that the training program use the most updated educational tools and breastfeeding and IYCF standards developed by WHO/UNICEF, as these standards represent optimal feeding practices and how to achieve them. Without these guiding documents and standards, improper practices could be promoted and taught, ultimately harming breastfeeding and the health of mothers and infants.
• Community health workers may be viewed as second-rate and not as legitimate or knowledgeable as doctors, decreasing the trust mothers and families have in their health care and advice (1). Careful handling of expectations and marketing of community health providers may be necessary to mitigate this risk.

Scaling Up Considerations

• It is important for CHWs to be both from the community and selected/supported by the community in order to 1) have true insight on how to improve health on the ground and 2) to obtain trust from the community. Without trust in the health worker, mothers are less likely to take health recommendations. The SS in Bangladesh are a good example of the type of CHW most able to make an impact: these women volunteer and are selected from the village health and development committee and are officially confirmed by a multi-sectorial group comprised of BRAC staff, local village leaders, and government officials. The woman must be between the ages of 25 and 35, married with no children under five years, and be clearly supported as a candidate by her community (1).

• It is important that the training program be consistent across a country and be based on WHO/UNICEF documents and standards regarding IYCF, as these represent optimal feeding practices and how to achieve them.

Barriers to Implement

• One report cites that the CHW program has challenges with supervision and accountability so it’s important that a monitoring/supervision program is in place to ensure quality health care is delivered in the community (1).

• Community health workers may be viewed as second-rate and not as legitimate or knowledgeable as doctors, decreasing the trust mothers and families have in their health care and advice (1).

Equity considerations

• Alive & Thrive’s 2009 initiative targeted specific districts with their community health worker training and outreach (3). These districts experienced improved feeding practices while others did not benefit from the same health outcomes. It is important that any training and outreach initiative attempt to serve all populations and districts where possible.

References:

1. Henry Perry, R. Z., Kerry Scott, Dena Javadi, and Jess Gergen. (2013). Case Studies of Large-Scale Community Health Worker Programs: Examples from Bangladesh, Brazil, Ethiopia, India, Iran, Nepal, and Pakistan. Retrieved from http://www.mchip.net/sites/default/files/mchipfiles/17_AppB_CHW_CaseStudies.pdf
2. BRAC. (2016). Bangladesh Annual Report 2016. Retrieved from http://www.brac.net/sites/default/files/annual-report/2016/Bangladesh-Annual-Report-2016.pdf
3. Alive & Thrive. (2014). Getting strategic with interpersonal communication: Improving feeding practices in Bangladesh. Retrieved from http://aliveandthrive.org/wp-content/uploads/2014/11/Getting-strategic-with-IPC-Bangladesh-June-2014.pdf
4. UNICEF. (2013). Bangladesh Nutrition Profile 2013. Retrieved from https://data.unicef.org/wp-content/uploads/country_profiles/Bangladesh/Nutrition_BGD.pdf
5. UNICEF (2015). Country Data-Bangladesh. Retrieved from https://data.unicef.org/country/bgd/
6. Alive and Thrive. (2013). Implementation Manual for BRAC’s Community-based Alive & Thrive Infant and Young Child Feeding Program in Bangladesh. Retrieved from https://www.fhi360.org/sites/default/files/media/documents/alive-thrive-Getting-strategic-with-IPC-Bangladesh-June-2014.pdf
7. Institute of Public Health Nutrition, Directorate of Health, Ministry of Health and Family Welfare, Bangladesh. (2011). National Training Manual on Infant and Young Child Feeding. Retrieved from http://aliveandthrive.org/wp-content/uploads/2014/11/Bangladesh-National-Training-Manual-on-IYCF-English.pdf
8. Mannan, I., Rahman, S. M., Sania, A., Seraji, H. R., Arifeen, S., Winch, P., . . . Baqui, A. (2008). Can Early Postpartum Home Visits by Trained Community Health Workers Improve Breastfeeding of Newborns? Journal of Perinatology, 28(9): 632-640. Retrieved from http://www.nature.com/jp/journal/v28/n9/abs/jp200864a.html