Bangladesh has made remarkable strides in healthcare in the four decades since independence. Since the 1990's maternal mortality has dropped from 574 to 194 deaths per 100,000 live births, and child mortality from 133 to less than 32 per 1,000 live births. Over four decades, the contraceptive prevalence rate has gone up seven to eightfold. In the 1980's, when immunisation coverage was two per cent, the shared roles and activities of BRAC and the government improved the status to 70 per cent within the last four years. The current status of fully immunised children is at 86 per cent. Despite the achievements, Bangladesh still suffers a high burden of deaths and diseases. Over 70 per cent of people seek care from informal health care providers and 62 per cent of those health providers practicing modern medicine have little or no formal schooling. One thirds of births take place at home, mostly assisted by unsupervised, untrained birth attendants. Recognising these problems, we have created a pool of frontline community health workers, the shasthya shebikas and shasthya kormis, who strive to address the crisis of human resources in the health sector by playing a substantial role in providing accessible and affordable services to the majority of the population.
Initiated in 1991, Essential Health Care (EHC) has revolutionised the primary healthcare approach in Bangladesh reaching millions with low cost basic promotive, preventive and curative services through our cadre of frontline community health workers. The goal of EHC is to improve access to essential health services through delivering community care and organising a bridging network with public healthcare system. Shashtyashebikas and shasthyakormis are mainly part of Essential Health Care (EHC) Programme. In fact, EHC is the basic platform of Health, Nutrition and Population Programme. All health interventions of BRAC are fundamentally based on the platform of EHC programme. To provide these services to the doorstep of millions of people would have required huge investment in the traditional system because of the large number of employees involved in the system. However, EHC developed a very innovative entrepreneurship model where the primary service deliverer (shasthyashebika) provides voluntary service. Although they do not receive any salary or monthly stipend, they are provided with financial incentives on the sale of basic medicines and selected health commodities to their community. This low cost innovative service delivery strategy has attracted various donors and partners in BRAC’s health programme because BRAC can deliver the service very effectively with a much lower cost.
We have started maternal, neonatal and child health (MNCH) programmes in 2005 as a pilot project and has been scaled up to 11 city corporations and14 rural districts in partnership with the government, UKAID and Australian High Commission. We have demonstrated that with limited resources, it is possible to change behaviour and practices to lower the incidences of maternal and neonatal deaths within a short period. With the active engagement of community health workers and birth attendants, we ensure high coverage of antenatal and postnatal care while supporting skilled birth attendance. More importantly, an innovative referral system is developed which facilitates transfer of acute emergency cases to hospitals. Within three to four years, we have observed a decline in maternal and neonatal deaths in both urban slums and rural districts.
Bangladesh has made a remarkable progress toward tuberculosis control since the inception of the Directly Observed Treatment Short- course (DOTS) strategy in 1993. In 1994, BRAC became the first NGO in the country to sign a memorandum of understanding with the government and expanded DOTS services across the country through its diversified partners. The national TB control programme in Bangladesh has established effective partnership with the consortium of 43 NGOs led by BRAC to implement the programme throughout the countries. BRAC has been working in 297 sub-districts of 42 districts with the coverage of 93 million population. In BRAC supported areas, all forms of TB case notification rate has increased from 105 to 129 /100,000 population per year. From 2004 to 2013, more than 1.5 million TB patients have been treated; yielding present treatment success rate 93 per cent in BRAC supported areas which has exceeded the national target (85 per cent) and is the second highest treatment success rate in the world Bangladesh has also improved case notification for child TB, smear negative TB, extra-pulmonary TB and drug resistant TB. The contribution of shasthya shebika in detecting presumptive TB cases, collecting sputum for lab diagnosis and DOTS for TB is tremendous. The Global Fund plays important role to control TB programme in Bangladesh. Growing challenges like TB/HIV co-infection, TB/diabetes are also being prioritised. More initiatives will be taken to address vulnerable communities including people with high risk behaviour and marginalised socially excluded people for TB care services. Urban TB programme is also given special attention for further strengthening of the programme.
The malaria control programme is on track in terms of MDG targets and has shown considerable success among the people at risk from malaria. The National Malaria Control Programme (NMCP) established an effective partnership with the consortium of 21 NGOs led by BRAC to implement the programme in 70 sub-districts of 13 endemic districts. Through the funding of The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and Health, Population and Nutrition Sector Development Program (HPNSDP) of government of Bangladesh, the malaria control activities were scaled up and the quality of preventive, diagnostic and treatment services have been improved. BRAC is directly implementing the programme in high endemic three Chittagong hill tracts districts and in 2 sub-districts of Moulvibazar. BRAC’s community based models applied in malaria programme using a large workforce of local shasthya shebikas and shasthya kormis in managing malaria patients at doorstep, raising awareness on malaria prevention and health service utilisation. Malaria cases were reduced by 68per cent in 2013 comparing to baseline year 2008 and whereas death was reduced by 90 per cent at the same time. A total of 3,735,905 long lasting insecticidal nets (LLIN) were distributed and 4,231,689 ordinary bed nets were treated with insecticide in the same period. Recent malaria prevalence survey conducted in 2013, documented the decreasing of point prevalence of malaria from 4 in 2007 to 1.41 in 2013 per 1,000 populations based on RDT in malaria endemic districts. A good utilisation rate (>85 percent) of insecticidal bed net was observed among pregnant women and children under 5 years of age.
Malnutrition among children is one of the major problems of our country. To mitigate this problem, BRAC’s nutrition programme has been working at household and community level for creating awareness on nutrition. BRAC’s shasthya shebika and nutrition promoters visit households in their communities and provide counselling, coaching and demonstration. Moreover, they offer community-based management of acute malnutrition (CMAM) service to mother and child of 6 to 59 months who are affected by moderate accurate malnutrition by providing supplementary food. Nutrition programme creates awareness about adolescent girls’ nutrition and encourages mothers and family members about many issues like intake of healthy and various types of food, early initiation of breast feeding, exclusive breast feeding till 6 months, breast feeding for at least two years and initiation of complementary feeding after six months. Moreover, to prevent child malnutrition and anaemia, micro-nutrient powder sachets are distributed under maternal, infant and young child nutrition (MIYCN)home fortification programme. It helps to prevent anaemia of 6 to 59 months old child by providing required iron, vitamin and minerals.
In Bangladesh, around seven hundred thousand people suffer from cataract blindness. Moreover, around one fifty thousand people are becoming blind every year. BRAC started ‘Vision Bangladesh’ project with the aim to remove the backlog of cataract blindness. In this programme, cataracts are identified through local eye camp and patients are sent to various government and private hospitals for operation. Community health workers visit household in their community and aware people about eye problems. And if there is any complex case, they send the patients to nearby hospitals or health centres. Moreover, BRAC’s ‘Reading Glass for Improved Living’ project has been providing reading glasses to the people whose vision has become blurred due to age.