… I have had a lazy day at the home of the family I’m staying with in Bangladesh. The working week being Sunday to Thursday, today should have been full of presentations and plans, but a hartal, or strike, called by the main opposition party has brought the city to a stand-still and, for fear of violence on the streets, we’ve been warned to stay inside. Apparently, the main concern is bus prices – ten had been set on fire by this morning.
I should probably explain what I’m doing here. I’m in Bangladesh. That wasn’t originally the plan. Intending to follow up my literature review (‘Project A’) in January on community health workers delivering family planning in Sub-Saharan Africa, I had hoped to go to Tanzania to carry out some field research (‘Project B’). Of course, things never quite work out as planned, especially when it involves coordinating with a host you’ve never met in a country far from home. Tanzania fell through, and my supervisor recommended I try BRAC, a development NGO in Bangladesh. Fortunately, family planning is relevant the world over, not least in one of the most densely populated countries in the world (whose land is up to 50% underwater some years), and community health workers are a concept pioneered by the grass-roots BRAC; I applied for an internship, and, some weeks later, was aboard an Emirates flight to the Indian subcontinent.
Given the enforced confinement to the house today, I’ve tried to read some more about BRAC. It’s a fascinating organization, one that goes far beyond my limited focus on health – from micro-finance to agriculture to education. This is really important, even through the lens of health, as none of these can be taken in isolation – but trying to keep my project focussed on their health programme is not the easiest when the internship programme aims to cover them all. BRAC has been training volunteers from villages throughout Bangladesh from its inception, and their health programme takes a few key interventions which can be provided by these community health workers – or shasthya shebikas - and delivers them as an ‘Essential Health Care’ package. The particular component I am interested in relates to family planning – what methods they provide, to whom, and how.
The idea of Community Health Workers is one that I’ve read much about over the last year. When I began the International Health BSc course, I felt a bit of a misfit – purposeless. Not for want of enthusiasm – I had finally rediscovered the reason why I entered medicine. But many of my classmates – and friends through the student global health network, Medsin – had become interested in global health through some particular passion for an issue – refugee health, or HIV/AIDS, or climate change. I came to first Medsin, and then the International Health course, more through mobilising students for global health – i.e. through Medsin – than in a particular area of interest. I felt this was something I lacked; I found myself looking more generally, at systems problems, for my niche.
I think I first came across Community Health Workers as a concept when reading a paper from Haiti, by some researchers from the organization Partners in Health. My reason for reading the paper wasn’t entirely academic – a friend had lent me Tracy Kidder’s Mountains Beyond Mountains the summer before, and I had become enamoured with PIH – a part of me hoped to focus on their work so that I might end up undertaking my Project B under their auspices. This was highly optimistic – the friend who had lent me the book had had similar aspirations at one time, and emailed the organisation for an entire year before eventually getting through (and accidentally seeing the email from head office: ‘I know we don’t normally accept volunteers, but this guy doesn’t seem to want to give up’).
The essay for which I read that paper turned out as can be expected from an ardent fan – far from critical or balanced, my references were largely from a small group of authors, and I failed to go beyond the conclusions they offered – which the marker took no small pleasure in highlighting to me. Nonetheless, the central concept – that community health workers can be a cornerstone in providing or increasing uptake of primary healthcare amongst the poorest and most vulnerable groups – stayed with me.
I read more. For another assignment, I produced a poster on community health workers delivering TB treatment in Bangladesh (not knowing that I would end up meeting some of them). For our non-communicable disease assignment, I wrote about lay mental health workers in India. Interestingly, as much as CHWs can be crucial in overcoming the human resource crisis in health facing many developing countries, much of the literature came from the USA: there was something about the concept which was more than simply a cheap stop-gap for missing health personnel. CHWs are a unique resource that have valuable qualities in themselves: they are of the communities they serve, and so are familiar with both the people and the problems. They are far from perfect, but in a world with rising healthcare costs, increasing co-morbidities, and a renewed emphasis on the Alma-Ata principles of Primary Health Care, there are few people better placed to tackle these challenges.
Community Health Workers can challenge our preconceptions of how a healthcare system should run, sometimes in quite awkward ways: in some studies, they have been shown to achieve the same and, sometimes, better results for particular (limited) interventions than their physician counterparts. While their diagnostic and technical skills are necessarily limited, given their short training, CHWs can effectively screen for common ailments that have safe, evidence-based treatments – for example, pneumonia in infants. They can also promote healthy practices – including family planning – and deliver the means to do so – for example, condoms or the oral contraceptive pill. For treatment of long-term conditions, whether for six- to nine-months, as for TB (which requires medication to be taken under direct observation every day), or for life, such as for hypertension, diabetes, or HIV, CHWs can support patients in adhering to their medications, ‘accompanying’ them through their treatment (a concept promoted by PIH, who called their CHWs ‘Accompagnateurs‘).
For BRAC, who started out by organising the poor into Village Organisations, training some of their members to become community health workers was a natural step to take. In line with much of their work, they focused on women, and the empowerment that such training could give: the shashthya shebikas were sold the EHC medicines at cost from BRAC, and were able to sell them for a small mark-up to their patients, earning themselves both an income and the respect of their communities.
Much like my first essay, in which I sang the praises of Partners in Health, my reading today has all been disseminated from BRAC; while a rigorously self-critical organisation (again, by its own account), there can be no doubt that there remain barriers to their programme. In the coming weeks, I hope to talk to some of the shashthya shebikas in person, as well as their supervisors and the health programme managers, in order to get a fuller picture. With the Bangladesh Ministry of Health and Family Welfare moving away from community-outreach towards a facility-based service (reviving the previously dilapidated network of Community Clinics), whether BRAC steps up to fill the gap or follows the same pattern remains to be seen.
In the meantime, I’ll sit out the hartal, and read some more.