REACHOUT at the Global Symposium on Health Systems Research
01 October 2018
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Bangladesh is facing rapid urbanisation.The limited number and quality of public health providers, and the poor availability of drugs and equipment, has led to under-use of government services and to high levels of use of community health workers and other private services in a wide variety of settings. The role of community health workers in providing preventive and curative care to the population is enormous and diverse. One single non-governmental organisation (NGO), BRAC, employs 80,000 community health volunteers, providing basic health services and contributing to improving population health outcomes. Close-to-community providers are recognised as having potential in Bangladesh, but they need to adapt to an environment in which they must compete with other providers and prove their competence. There are about 62,000 unregistered pharmacies in the country. Overall, the health system accommodates multiple forms of practice with varying degrees of legitimacy.
The need to understand the interactions between the many diverse close-to-community providers is becoming a health priority.In Bangladesh’s evolving and pluralistic health system, the interactions between community health workers and informal private practitioners, particularly in urban areas, are unclear. Informal practitioners vary significantly according to their knowledge and the position they hold in the broader health market supply chain, and in their interactions with community health workers. It is thought that in urban slums it is poor and marginalised communities in particular that access informal practitioners for stigmatised health issues, such as sexually transmitted diseases and sexual and reproductive health. It is important to better understand access to services and interactions between slum communities, informal private practitioners, and community health workers.
Informal practitioners, including community health workers, lack the necessary training and capacity to provide basic curative services rationally. They also have poor knowledge about drugs. Sometimes they provide unnecessary and harmful medications, or fail to refer serious cases. Although there have been some studies of their knowledge and treatment practices, information is still inadequate to develop appropriate intervention programmes to minimise harmful practices.
At the provider level community health workers and informal providers are embedded within communities and can contribute significantly to implementing health promotion programmes and disease prevention programmes. However to date their opportunities to participate in capacity development and training has been limited. Community health workers lack professional qualifications, and the volunteering system has created a problem of high turnover which has had an impact on the quality of services delivered. Very little is known about the incentive mechanisms, referral processes, and links between informal and private providers as the first line in health care provision. A comprehensive assessment of quality assurance and monitoring and evaluation is needed to tackle these issues.
At the policy level, Bangladesh needs to strengthen the links between research, policy and practice. Research can be uncoordinated, leading to duplication and replication. Policy makers are not always aware of what is going on at local level and community level. There is no engagement with health information providers and there is a clear need to develop the evidence base and policy on this.
Focusing on sexual and reproductive health, REACHOUT will map close-to-community services in urban slums and then develop monitoring and evaluation tools to gain insight into the perspectives and interactions of community health workers and informal practitioners. The aim is to provide better support to enable community health workers to provide good quality services for slum communities. REACHOUT will also explore how human resource management strategies can work in a pluralistic healthcare environment characterised by high turnover. By engaging policy makers, researchers, and other stakeholders involved in the health system REACHOUT will try to develop appropriate standardised training and workshops to improve the knowledge and treatment practices of informal providers. This approach will develop the capacity of the health system to meet the needs of slum communities.
This project is funded by the European Union.