Program Comparison

Priority goals of CHW program

• Increase coverage of key interventions requiring behavior change (family planning, use of oral rehydration therapy for treatment of childhood diarrhea, immunization, etc.)

• Ensure appropriate use of primary health care (PHC) services

• Help population navigate health and welfare systems

• Support healthy behaviors

• Increase geographic access to PHC services

• Address high burden of preventable diseases

• Provide PHC services in remote and rural communities

• Increase resilience of health system

Relevant context

• Health system with multiple actors and large private sector

• Low government health expenditure per capita

• Significant health system reform to ensure universal access to healthcare, with focus on equity

• High burden of non-communicable diseases

• Highly centralized, mostly public PHC system

• Highly constrained human resources for health

• Post-Ebola epidemic, with a range of NGOs working in community health

• Large rural population living in remote areas

Key program features

• Diverse ecosystem of government and NGO CHWs, with different training and service packages

• Mix of paid, full-time CHWs and part-time volunteer cadres with income-generation activities

• Developing since the 1970s, to respond to evolving health priorities (e.g. family planning in the 1970s, child health in the 1980s, etc.)

• BRAC is the largest NGO program in Bangladesh, with ~50 percent of all CHWs in country

• Full-time CHWs integrated into PHC teams in context of national PHC reform

• Home visits and community activities to support demand for and utilization of PHC services, as well as uptake of other welfare services

• Focus on maternal, newborn, and child health (MNCH) (e.g. ANC, immunization), chronic diseases (e.g. ensuring proper follow-up), identification of other family needs

• Full-time, female CHWs extending geographical reach of PHC services

• 12-month training (5-10x longer than other programs), with range of curative and prevention/promotion services

• Services delivered both at community/homes and health posts

• Manage Health Development Army Volunteers, ~three million women providing role model to peers on prevention/promotion practices

• Part-time CHWs providing curative and prevention/promotion services in hard-to-reach areas

• Dedicated nurse supervises CHWs and provides link to facility-based PHC

• Services provided at community and home level

• Program managed by government, in partnership with NGOs

Types of CHW Cadres (hours/week indicated in part-time cadres)

Government Cadres:

• Family Welfare Assistant (FWA)

• Health Assistant (HA)

• Community Health Care Provider (CHCP)

BRAC Cadres:

• Shasthya Shebika (SS) (~20h/week)

• Shasthya Kormi (SK)

• ACS: Community Health Agent (full-time)

• HEW: Health Extension Worker (full-time)

• HDAV: Health Development Army Volunteer (~three hours/day)

• CHA: Community Health Assistant (20h/week)

Curative

• Only CHCPs and SKs: treatment of pneumonia, diarrhea and malaria; TB DOTS; some CHCPs conduct safe deliveries

• None

• Only HEWs: treatment of pneumonia, diarrhea and malaria; TB DOTS; some HEWs conduct safe deliveries

• Treatment of pneumonia, diarrhea and malaria in children under five, and pregnant women.

Promotion

• Provide childhood illness education to mothers, nutrition, and water, sanitation and hygiene (WASH) education

• Check immunization cards and recommend appropriate immunization, design, organize, and deliver group education meetings and counseling for individuals with chronic disease, pregnant women and women with newborns, provide information on services available at PHC center and refer as needed

• Provide childhood illness education to mothers, nutrition and WASH education

• Provide childhood illness education to mothers, nutrition education

Prevention

• Prevent neonatal sepsis, administer immunizations, identify and manage malnutrition, identify pregnant mothers, provide antenatal and postnatal care (ANC/PNC) - only CHCP/SK, preventive education on neglected tropical diseases (NTDS), non-communicable diseases (NCDs), HIV, tuberculosis (TB), and provide family planning (FP) distribution

• Identify risk factors in the home, measure blood pressure/glycemia, provide 1:1 counseling on cancer and other NCDs, HIV, TB healthy behaviors and FP, schedule ANC/PNC and general PHC appointments, follow up to ensure attendance and support and adherence to medication (e.g. for diabetes)

• Prevention of neonatal sepsis, administer immunizations, identify and manage malnutrition, identify pregnant mothers, provide ANC/PNC (only HEW), deliver preventive education on NTDS, NCDs, HIV, TB, and provide FP distribution

• Identify danger signs and provide referrals for pregnant women and children, identify pregnant mothers and provide them with referrals for ANC/PNC and facility-based deliveries, identify and manage malnutrition, vaccination dropout tracing, preventive education on NTDS, NCDs, HIV, TB, provide FP distribution, and basic first aid response

Community Mobilization

• National vitamin A, immunization and campaigns, family planning satellite mobile clinics

• Determine health needs, conduct advocacy, promote and mobilize on identified health needs

• Determine health needs, conduct advocacy, promote and mobilize on identified health needs

• Determine health needs, events-based surveillance for infectious diseases, immunization and campaigns, mobilize on identified health needs

Other Tasks

• Data collection, vital record registration

• Household visits

• Attend supervision meetings; SS supervises SK

• Referrals to PHC facilities

• BRAC SS sell various health commodities and medicines for income generation

• Data collection, vital record registration

• Household visits

• Engage closely and regularly with PHC team

• Referrals to PHC facilities

• Navigation to social services

• Data collection, vital record registration

• Household visits

• Attend supervision meetings with PHCU team, HEW supervises HDAV

• Referrals to PHC facilities

• Train model families

• Data collection, vital record registration

• Household visits

• Attend supervision meetings with CHSS

• Referrals to PHC facilities