Community health workers at the dawn of a new era: 11. CHWs leading the way to "Health for All".

BACKGROUND: This is the concluding paper of our 11-paper supplement, "Community health workers at the dawn of a new era". METHODS: We relied on our collective experience, an extensive body of literature about community health workers (CHWs), and the other papers in this supplement to identify the most pressing challenges facing CHW programmes and approaches for strengthening CHW programmes. RESULTS: CHWs are increasingly being recognized as a critical resource for achieving national and global health goals. These goals include achieving the health-related Sustainable Development Goals of Universal Health Coverage, ending preventable child and maternal deaths, and making a major contribution to the control of HIV, tuberculosis, malaria, and noncommunicable diseases. CHWs can also play a critical role in responding to current and future pandemics. For these reasons, we argue that CHWs are now at the dawn of a new era. While CHW programmes have long been an underfunded afterthought, they are now front and centre as the emerging foundation of health systems. Despite this increased attention, CHW programmes continue to face the same pressing challenges: inadequate financing, lack of supplies and commodities, low compensation of CHWs, and inadequate supervision. We outline approaches for strengthening CHW programmes, arguing that their enormous potential will only be realized when investment and health system support matches rhetoric. Rigorous monitoring, evaluation, and implementation research are also needed to enable CHW programmes to continuously improve their quality and effectiveness. CONCLUSION: A marked increase in sustainable funding for CHW programmes is needed, and this will require increased domestic political support for prioritizing CHW programmes as economies grow and additional health-related funding becomes available. The paradigm shift called for here will be an important step in accelerating progress in achieving current global health goals and in reaching the goal of Health for All.

Microbial contamination of drinking water from risky tubewells situated in different hydrological regions of Bangladesh.

This study, conducted in 40 selected upazilas covering four hydrological regions of Bangladesh, aimed at determining the risk of selected shallow tubewells (depth<30m) used for drinking purpose (n=26,229). This was based on WHO's sanitary inspection guidelines and identifying the association of sanitary inspection indicators and risk scores with microbiological contamination of shallow tubewells. The main objective of the study was to observe the seasonal and regional differences of microbial contamination and finally reaching a conclusion about safe distance between tubewells and latrines by comparing the contamination of two tubewell categories (category-1: distance ≤10m from nearest latrine; n=80 and category 2: distances 11-20m from nearest latrine; n=80) in different geographical contexts. About 62% of sampled tubewells were at medium to high risk according to WHO's sanitary inspection guidelines, while the situation was worst in south-west region. Microbiological contamination was significantly higher in sampled category-1 tubewells compared to category-2 tubewells, while the number of contaminated tubewells and level of contamination was higher during wet season. About 21% (CI95=12%-30%), 54% (CI95=43%-65%) and 58% (CI95=46%-69%) of water samples collected from category-1 tubewells were contaminated by E. coli, FC, and TC respectively during the wet season. The number of category-1 tubewells having E.coli was highest in the north-west (n=8) and north-central (n=4) region during wet season and dry season respectively, while the level of E.coli contamination in tubewell water (number of CFU/100ml of sample) was significantly higher in north-central region. However, the south-west region had the highest number of FC contaminated category-1 tubewells (n=16 & n=17; respectively during wet and dry season) and significantly a higher level of TC and FC in sampled Category-1 tubewells than north-west, north-central and south-east region, mainly during wet season. Multivariate regression analysis could identified some sanitary inspection indicators, such as tubewell within <10m of latrine, platform absent/broken, pollution source (i.e. household's waste dumping point/poultry/dairy farm) within 10m of tubewell and unimproved sanitation facility which were significantly associated with presence of microbial contaminants in tubewell water (p<0.01). A tubewell with high risk level was associated with a higher chance of having FC and TC in tubewell water than a tubewell with a medium risk during wet season, but no such conclusion could be drawn in case of E.coli contamination. Construction of pit latrine in areas with high water table should be highly discouraged. Raised sealed pits or flush/pour flash to septic tank could be installed considering sanitary inspection criteria. Water should be treated before drinking.

Informal sector providers in Bangladesh: how equipped are they to provide rational health care?

In Bangladesh, there is a lack of knowledge about the large body of informal sector practitioners, who are the major providers of health care to the poor, especially in rural areas, knowledge which is essential for designing a need-based, pro-poor health system. This paper addresses this gap by presenting descriptive data on their professional background including knowledge and practices on common illnesses and conditions from a nationwide, population-based health-care provider survey undertaken in 2007. The traditional healers (43%), traditional birth attendants (TBAs, 22%), and unqualified allopathic providers (village doctors and drug sellers, 16%) emerged as major providers in the health care scenario of Bangladesh. Community health workers (CHWs) comprised about 7% of the providers. The TBAs/traditional healers had <5 years of schooling on average compared with 10 years for the others. The TBAs/traditional healers were professionally more experienced (average 18 years) than the unqualified allopaths (average 12 years) and CHWs (average 8 years). Their main routes of entry into the profession were apprenticeship and inheritance (traditional healers, TBAs, drug sellers), and short training (village doctors) of few weeks to a few months from semi-formal, unregulated private institutions. Their professional knowledge base was not at a level necessary for providing basic curative services with minimum acceptable quality of care. The CHWs trained by the NGOs (46%) were relatively better in the rational use of drugs (e.g. use of antibiotics) than the unqualified allopathic providers. It is essential that the public sector, instead of ignoring, recognize the importance of the informal providers for the health care of the poor. Consequently, their capacity should be developed through training, supportive supervision and regulatory measures so as to accommodate them in the mainstream health system until constraints on the supply of qualified and motivated health care providers into the system can be alleviated.

Community-based kangaroo mother care to prevent neonatal and infant mortality: a randomized, controlled cluster trial.

OBJECTIVE: We adapted kangaroo mother care for immediate postnatal community-based application in rural Bangladesh, where the incidence of home delivery, low birth weight, and neonatal and infant mortality is high and neonatal intensive care is unavailable. This trial tested whether community-based kangaroo mother care reduces the overall neonatal mortality rate by 27.5%, infant mortality rate by 25%, and low birth weight neonatal mortality rate by 30%. METHODS: Half of 42 unions in 2 Bangladesh divisions with the highest infant mortality rates were randomly assigned to community-based kangaroo mother care, and half were not. One village per union was randomly selected proportionate to union population size. A baseline survey of 39,888 eligible consenting women collected sociodemographic information. Community-based workers were taught to teach community-based kangaroo mother care to all expectant and postpartum women in the intervention villages. A total of 4165 live births were identified and enrolled. Newborns were followed for 30 to 45 days and infants were followed quarterly through their first birthday to record infant care, feeding, growth, health, and vital status. RESULTS: Forty percent overall and approximately 65% of newborns who died were not weighed at birth, and missing birth weight was differential by study group. There was no difference in overall neonatal mortality rate or infant mortality rate. Except for care seeking, community-based kangaroo mother care behaviors were more common in the intervention than control group, but implementation was weak compared with the pilot study. CONCLUSIONS: The extensive missing birth weight and its potential bias render the evidence insufficient to justify implementing community-based kangaroo mother care. Additional experimental research ensuring baseline comparability of mortality, adequate kangaroo mother care implementation, and birth weight assessment is necessary to clarify the effect of community-based kangaroo mother care on survival.

Human resources for health: overcoming the crisis.

In this analysis of the global workforce, the Joint Learning Initiative-a consortium of more than 100 health leaders-proposes that mobilisation and strengthening of human resources for health, neglected yet critical, is central to combating health crises in some of the world's poorest countries and for building sustainable health systems in all countries. Nearly all countries are challenged by worker shortage, skill mix imbalance, maldistribution, negative work environment, and weak knowledge base. Especially in the poorest countries, the workforce is under assault by HIV/AIDS, out-migration, and inadequate investment. Effective country strategies should be backed by international reinforcement. Ultimately, the crisis in human resources is a shared problem requiring shared responsibility for cooperative action. Alliances for action are recommended to strengthen the performance of all existing actors while expanding space and energy for fresh actors.

Anaemia and iron deficiency during pregnancy in rural Bangladesh.

OBJECTIVE: To study the prevalence of anaemia and its association with measures of iron deficiency (ID) among a group of pregnant women. DESIGN: Cross-sectional survey. SETTING: Pregnant women identified through house-to-house visits and participating in community-based antenatal care activities in a rural location of Mymensingh, Bangladesh. SUBJECTS: The estimates are based on 214 reportedly healthy pregnant women in their second trimester. Information on socio-economic status and reproductive history were obtained through home visits and venous blood samples were collected at antenatal care centres. Haemoglobin concentration (Hb) was measured by HemoCue, serum ferritin (sFt) by radioimmunoassay and serum transferrin receptor (sTfR) by enzyme-linked immunosorbent assay methods. ID was defined as presence of either low sFt (<12 microg l(-1)) or high sTfR (>8.5 mg l(-1)). RESULTS: The prevalence of anaemia (Hb <110 g l(-1)) was 50%, but severe anaemia (Hb <70 g l(-1)) was absent. Low sFt was observed in 42%, high sTfR in 25%, either low sFt or high TfR in 54% and both low sFt and high TfR in 13% of the pregnant women. Two out of three anaemic women had an indication of ID, which was present in 80% of women with moderate (Hb 70-99 g l(-1)) and 50% with mild (Hb 100-109 g l(-1)) anaemia. Four out of 10 non-anaemic women (Hb >/=110 g l(-1)) also had ID, but the prevalence was significantly lower than that observed in anaemic women (P=0.001). CONCLUSIONS: Despite the high prevalence of anaemia, severe cases were absent. The prevalence of ID increased at lower Hb. However, an increased prevalence was also found among women in the highest category of Hb.

Changing health-seeking behaviour in Matlab, Bangladesh: do development interventions matter?

It is generally assumed that socioeconomic development interventions for the poor will enhance their material and social capacities to prevent ill health and to seek appropriate and timely care. Using cross-sectional data from surveys undertaken in 1995 and 1999 as part of the BRAC-ICDDR,B Joint Research Project in Matlab, Bangladesh, this paper explores patterns of health-seeking behaviour over time, with the hypothesis that exposure to integrated socioeconomic development activities will enhance gender equity in care-seeking and the use of qualified medical care. While there is tentative evidence of greater gender equity in treatment choice among households benefiting from development interventions, a preference for qualified medical care is not apparent. Findings reveal a striking and generalized rise in self-treatment over the 4-year period that is attributed to the economic repercussions of a major flood in 1998, and greater heath awareness due to the density of community health workers in Matlab. Also noteworthy is the substantial reliance on informal and often unqualified practitioners (over 20%) such as pharmacists and itinerant drug sellers. Factors associated with the type of health care sought were identified using logistic regression. Self-care is associated with female gender, the absence of low cost health services and illnesses of relatively short duration. Medical care, on the other hand, is positively predicted by male gender, geographic location, greater socioeconomic status and serious illness of long duration. The paper concludes by emphasizing the importance of enhancing local capacities to determine whether self-treatment is indicated, to self-treat appropriately, or in cases where health care is sought, to judge provider competence and evaluate whether treatment costs are justified. The provision of pharmaceutical training to the full spectrum of health care providers is also recommended.

Beneficial effects of a woman-focused development programme on child survival: evidence from rural Bangladesh.

This paper reports results from a prospective study of the impact of a woman-focused development programme on child survival in Matlab, a rural area of Bangladesh. The programme was targeted to households owning less than 50 decimals of land and members selling more than 100 days of labour for living in a year. Programme components included formation of women's groups for saving and credit, training on skill development, functional literacy including legal and social awareness, and technical and marketing support to projects undertaken with the loan money from the organization. A total of 13,549 children born alive during 1988-97 in the study area were included in the study. Hazards of mortality during pre- and post-intervention periods were compared among the programme participants and non-participants controlling the effects of other relevant variables. There has been a substantial reduction in mortality during the post-intervention period; however, the reduction was much greater for infants whose mothers participated in the development programme compared to infants of non-participant mothers from similar socioeconomic background. In a relative sense, there has been a 52% reduction of the pre-intervention level hazard of death of children during infancy of participant mothers compared to 31% reduction for the infants of non-participant mothers from similar socioeconomic background. There had also been a substantial reduction in hazard of death during childhood (1-4 year age group), however, the reduction was statistically similar for all groups of children irrespective of their mothers' participation in the development programmes.

Measuring perceived health outcomes in non-western culture: does SF-36 have a place?

This study explored the usefulness of a generic health assessment tool SF-36 in measuring perceived health outcomes in a developing-country setting. The adapted Bangla version was administered in 10 villages of Matlab sub-district in Bangladesh during second half of 1999. Respondents included currently-married males and females selected randomly from households stratified according to their association with women-focused development interventions of BRAC. Findings revealed that the respondents from BRAC households perceived their health status marginally better than the poor non-member group in most domains studied, sometimes significantly so, e.g. general and mental health (p < 0.05). The respondents from BRAC reported better 'current health' than their non-member counterparts. The gender difference in assessment of health status was noted among the groups. Age, education, and poverty were important determinants of perceived health status. SF-36 proved to be a useful tool for self-assessment of health status and group comparison when properly modified for cross-cultural adaptation.