The BRAC health programme addresses the health and nutritional status of women and children in Bangladesh and covers 120 million people with approximately 60,000 Shasthya Shebikas (SSs) and 6,000 Shasthya Kormis (SKs). The concept of SS was first introduced in 1977 through a small-scale integrated health development programme in five sub-districts. Subsequently the approach was found to be successful and expanded.
All Shasthya Shebikas (health workers) of BRAC are female. They are selected from the community. Based on the criteria, the final selection of SS is done with the support of community people and BRAC staff.
The breadth of the health activities of SS in community based health care is quite extensive, especially considering that SSs are illiterate (or, at best semi-literate) and unsalaried. The SSs give health education, motivation and mobilisation regarding different components of the health programme.
Each SS facilitates almost 500 households for their health care needs and also links them up with BRAC's multi-dimensional development interventions. The second front line health workers are the Shasthya Kormis. Unlike the SSs, SKs are paid a monthly salary. To qualify to be a SK they must be married, acceptable to the communities and have passed class 10 in school.
After the selection, the SS is given a 17-day basic training held at the BRAC regional offices. They also participate in monthly refresher training and are provided specific orientation training on issues like maternal, neonatal and child health, nutrition, TB and malaria etc. as needed.
BRAC has been able to scale-up its health programmes through replication of best practices. A strong monitoring and evaluation programme made it possible to identify weaknesses that could be corrected before scaling up to the next level.
The process of becoming a SS has changed the scenario for the poor rural women in Bangladesh; they have been transformed from an ordinary, relatively unknown figure to a well-known public entity in the community. Initial disapproval from the husband and other family members usually give way to appreciation as they could see tangible economic benefits of the SS work.
The SS is initially given a fixed revolving fund for buying essential medicines and various health commodities from BRAC at cost price which is then sold at a mark-up price to the consumers and the difference is kept by her as incentive. This concept has established a strong and successful linkage between the community and BRAC. The SS does not only get empowered in the community, but also is benefitted financially leading to economic enablement. The identity of SS has given them an improved status in the family, increased their credibility in the informal credit market and appreciation in the community.
BRAC’s Shasthya Shebika approach demonstrates that even illiterate or semi-literate rural women can be trained to deliver preventive, promotive and basic curative services for common illnesses to the community. The initial resistance that they face gives way to gradual acceptance when the family and the community see the tangible benefits, including financial benefits, from the SS work.
Financial incentives are not the sole motivation behind one’s aspiring to become a SS as has been described earlier and attention to non-financial incentives such as appreciation by the supervisors and the community is also needed. Other factors like community acceptability, family cooperation, social status etc. also play an important role for sustainability of the model.
A basic lesson is that the Community Health Workers (CHWs) must be adequately supported and such support requires more resources from the government or communities than what are spent now on CHW programmes. By developing strong, better educated and empowered women and village groups, sustainable improvements can be achieved and a higher quality of preventive health measures can be practiced in the community.