Crisis of health workforce in Bangladesh: a non-government organization’s experience in deploying community health workers in primary health care

Bangladesh has many success stories in health, including its on-track progress in achieving the millennium development goals (MDGs).1,2 Yet, the country is suffering a huge shortage of workforce in the health sector, particularly doctors, nurses and midwives.3,4 the Alma Ata Declaration in 1978 reiterated the importance of primary Health Care (pHC)5 and the role of community health workers (CHWs) in responding to the healthcare needs of the people.6 in addressing this human resource gap, an innovative CHW initiative has shown promising results, including recruitment and retention of staff, health system performance and health outcomes.Development of ChwsCollaborative working between government and non-government organizations (NGos) has enabled better utilization of human resources, particularly in the use of front-line health workers. it is estimated that out of 219,000 CHWs in Bangladesh, 56,000 are government workers and 163,000 are from NGos, of which 105,631 are employed by the largest NGo in Bangladesh, 'BrAC' (formerly known as Bangladesh rural Advancement Committee).7,8 this means a collective resource of 13.7 CHWs per 10,000 populations, much higher than neighboring countries, such as, india, pakistan and Nepal.7recognizing the need for human resources in pHC, BrAC, an indigenous NGo, has pioneered the introduction of trained female CHWs to support disadvantaged populations.8 With knowledge of local context and needs, BrAC adapted the role of the CHW creating two new types known as Shasthya Shebika (SS) and Shasthya Kormi (SK). these workers promote good health, encourage community mobilization for health improvement, provide basic health services and link the community with the formal health system in rural areas and slums of cities and municipalities. the SSs, as the first front-line workers, are recruited from the community to serve 150-250 houses and are trained on basic preventive, health promotion and curative essential health care, which is backed up by regular monthly refresher training. the SKs are the second front-line CHWs trained by BrAC as paramedics, mostly offering basic antenatal and postnatal care, and who support, reinforce and supervise the activities of SSs. Going from house to house, the SKs and SSs explain family planning, provide antenatal and postnatal education and basic care, attend childbirth, offer newborn care, facilitate immunization, treat simple diarrheal diseases, counsel on nutritional behavior and practices and promote safe water, sanitation and hygiene.progress anD refleCtionsthe involvement of BrAC's CHWs in public health programs has shown positive results. tuberculosis case detection and treatment success rates are better where CHWs have been involved in communities.8 Health system management has improved where delays in seeking and accessing emergency obstetric care have reduced due to CHWs' involvement.9 Community empowerment is influenced by CHWs themselves being empowered, while also providing the bridge between the community and formal health systems.10the motivation and retention of CHWs has always been a challenge. in the late 1990s, the drop-out of SSs was 42%,11 improving to 12% in 2008,12 and recently is claimed to be as low as 5%-6%. introduction of incentives, continuous interactions through monthly refresher training and meetings, supportive field supervision and gaining a respectful position in the community have all boosted the motivation and retention of SSs. …