Over the past three years, Last Mile Health has partnered with research institutions in Bangladesh, Brazil, Ethiopia, and Liberia to identify trends on establishing and sustaining high-performing national community health worker programs. Together, these countries offer valuable lessons that are documented in the newly-launched Exemplars in Global Health.
The following blog is the third blog in a four-part series highlighting the Exemplars in Global Health Initiative. The case study can be found here and was written in collaboration with BRAC, and BRAC James P Grant School of Public Health, BRAC University.
Bangladesh’s community health workers have been in place nearly as long as the country has been independent. For almost 40 years, the pioneering community health worker program – one of the first in the world, having started largely as a family planning initiative – has helped deliver impressive health outcomes to one of the poorest and most densely populated countries. It has ushered in extraordinary change for a vastly underserved rural population of almost 100 million, including: a 75 percent reduction in under-five mortality; a 10-fold increase in contraceptive prevalence; and a 90 percent rate of increase for the administration of the DTP3 vaccine – which was almost zero in the 1980s.
But being first or having existed for 40 years is not what has made Bangladesh such a successful case study. Rather, the country’s malleability in working with partners to measure, learn from what works and does not, adapt and fine-tune its programming, and deliver efficient and effective care throughout the years has. Partner support in Bangladesh comes from various independent NGOs, many of them started by and for Bangladeshis. Despite their decentralized operating nature, they share priorities that have enabled great progress: emphasizing the empowerment of women; using data-driven decision-making; and keeping programming innovative and adaptable.
Through home visits, community health workers provide a range of services, including family planning, antenatal, postnatal and neonatal care and immunization. They also treat cases of childhood diarrhea, pneumonia, and malaria, and screen for undernutrition and provide nutrition counseling. Lastly, and equally as importantly, they use data collection as a basis for monitoring and evaluation so they can improve on their service delivery to the greater population.
Today, 130,000 community health workers and 13,000 community clinics (with 80 percent of the population is within a 30-minute walk from one) are part of a network of care that connects Bangladeshis – many of them for the first time – to the country’s formal healthcare system.
But the evolution of Bangladesh’s healthcare system has also helped usher a fundamental societal change in the country. Community health workers are mostly women, and because they engage regularly with local authorities and officials, they are seen as community leaders. This has, in turn, helped women expand their roles in other sectors, giving them a pathway to more forcefully pursue educational opportunities, financial literacy, and economic independence.
Despite this progress, challenges remain. One fourth of Bangladesh’s population still lives under the international poverty line (less than US$1.90 per day). The burden of non-communicable chronic disease has increased, the population is aging, and the government’s health expenditure is still the lowest in South Asia.
Addressing the community health worker program’s sustainability and ensuring coordination between partner organizations across the country to prevent duplication or fragmentation of services – so costs can be kept low and outcomes high – will be fundamental for Bangladesh to continue delivering results in the next 40 years and beyond.
About Exemplars in Global Health
Exemplars in Global Health is a program led by Gates Ventures and fueled by the research and insights of both in-country and global experts and partners, to identify the biggest global health success stories of our time. Exemplars in Global Health seeks to identify what public health interventions have delivered impact, how programs have been designed to circumvent challenges, and why specific interventions have led countries to become positive outliers of success. The program’s aim is to allow decision makers to explore proven strategies, policies and actionable recommendations that create similar pathways to scale their own success, in a faster, more effective manner.
To learn more about Bangladesh’s remarkable transformation, read the case study here.