Health care at scale via community health workers

by Anjali Sastry on October 13, 2009

Can clever models for delivering health care within the community enable care to reach the poorest? How much can wise ways of enrolling health workers into the care delivery effort address the apparently massive shortage of RNs, MDs, technical experts and other trained personnel?  According to the WHO:

Health workers are all people whose main activities are aimed at enhancing health. They include the people who provide health services — such as doctors, nurses, pharmacists, laboratory technicians — and management and support workers such as financial officers, cooks, drivers and cleaners. Worldwide, there are 59.8 million health workers. About two-thirds of them (39.5 million) provide health services; the other one-third (19.8 million) are management and support workers. Without them, prevention and treatment of disease and advances in health care cannot reach those in need.

Freedom from WantWe explored Bangladesh’s BRAC and its work in health care.  Our focus was the rural tuberculosis treatment program delivered by Shasthya Shebikas (also spelled Shastho Shebikas), women selected by village leaders as front-line, community-based health workers to funnel potential patients towards testing and then to offer medications and support to allow patients to recover from the disease.

This video, from a 2007 PBS series, offers an introduction to BRAC’s accomplishments in health-care delivery in resource limited settings.

The BRAC model includes training, performance monitoring, and continual assessment of what works and what doesn’t. Ian Smillie’s recent book, Freedom from Want: How Social Entrepreneurship Transformed 100 Million Lives, and Other Inspiring Stories from the Biggest Non Profit You’ve Never Heard Of, tells the BRAC story in dramatic detail. He describes the organization this way:

It is a leader because it is good at what it does. It also happens to be big, and there is an important correlation. A lot of good projects are never taken to scale. Pilot projects remain pilots because nobody picks them up. BRAC has found ways to take simple solutions to major health problems – such as diarrhea in children, a major killer – to every village in the country. It graduates half a million literate girls from its non-formal primary schools every year. Its dairy produces 90,000 litres of milk a day, all of it from people who have borrowed small amounts to buy one or two cows. BRAC is 80 percent self-financing, and it is now taking its work to other countries in Asia and Africa. This would be remarkable for a Canadian or a British NGO, but in a Bangladeshi NGO it is stunning.

For a broad introduction to BRAC, please see their youTube channel.BRAC blog

Back to their efforts in tuberculosis. What has been the impact of the 80,000 Shebikas who have delivered TB care in Banglasdesh via BRAC’s programs? A readable 2009 overview by Miriam Katz is entitled Collaboration In The Health Sector: The Case Of Bangladesh And Tuberculosis. And if you want details about the program, review BRAC’s Global Fund application for a wealth of information. To assess performance and need, you may also want to explore information on the country’s overall profile in TB.

For the  Kaiser Network on 11/11/2007, Jalaluddin Ahmed of BRAC Bangladesh presented “Case of Shasthya Shebika in Bangladesh;” and in more recently another informative BRAC presentation addressed Pay for Performance of Community Health Workers: BRAC’s Experience ( Taskeen Chowdhury, BRAC, at Pay for Performance Workshop,  January 19-23 2009 Cebu, Philippines). As further evidence of scaling up, BRAC’s TB program has now expanded to Afghanistan.

Now, what does the BRAC model have to do with human resources in global health? We examined it as an example of drawing on local communities for the daily health care delivery that diseases like TB necessitate. To analyze how the model may apply in other cases, draw on some of the useful resources listed here.

The HRH Global Resource Center is a global library of human resources for health (HRH) resources focused on developing countries. Access online support, many articles, and other resources.

The Global Health Workforce Alliance was created in 2006 as” a common platform for action to address the health workforce crisis. The Alliance is a partnership of national governments, civil society, international agencies, finance institutions, researchers, educators and professional associations dedicated to identifying, implementing and advocating for solutions.”  Look around the site for lots of useful information, from case studies to introductions to the key issues such as the global shortage of health workers and its impact and migration of health workers.

Studies on task shifting (such as this one) may help us to consider the question that frames this post: can creative and carefully tested ways of working with community health workers help meet the need for health care globally?

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